A Portrait of a Chart Note in Disarray
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When was the last time you read, from beginning to end, a really long chart note that helped you take better care of a patient?
Sometimes when I read a specialist’s notes (and even notes of some primary care providers) that go on for page after page, carrying forward every previous visit, it can be incredibly difficult to figure out what happened, what’s going on right now, what issue they were dealing with, and what the recommendations were.
Sure, you can sometimes skip to the end, right before the assessment and plan, and find the section of the note labeled “today’s visit” (sometimes with the added bonus of that day’s date). But this can be hard to pull out sometimes, as every paragraph seems to be labeled, “today’s visit.”
I recall one instance where I misunderstood and thought a patient was in the midst of getting a treatment that they had finished long ago, and it definitely delayed care. And another where I thought someone else was providing treatment, but they thought I was taking over, and neither of us ended up doing anything until that mess got cleared up.
When did it become “fashionable” to make each note a complete copy of the entire patient’s chart that came before?
We see notes with every part of the hospital course, every outpatient visit, every lab value, every imaging study, every procedure, cut-and-pasted into a non-hierarchical mess, that sometimes makes it hard to figure out what’s happened, what’s happening, and what should happen.
And doesn’t this go against the whole point of our notes?
Subjective, objective, assessment, and plan. That was always supposed to be it.
What I learned from the patient today, what I found on my exam, what I think is going on, and what I plan to do about it.
It’s true, sometimes the patient’s past medical and surgical history can inform, can provide an important reference, a sounding point from which to make today’s decisions better, some hidden nugget, a clinical pearl, to prevent the mistakes we made in the past, to see the whole picture.
But when bringing it all into today’s note ends up creating something that’s just too long to read, too big to get your head around, and just not that useful for making decisions, then maybe it’s time we do better.
In the old days, our paper charts got thicker and thicker as a patient’s medical course grew longer and more complex: more interactions with us, more complications, more pathways that we went down trying to get them healthy, more journeys with bumps along the way.
Now, much of this sits in the electronic medical record, right there for us whenever we need it.
So, in my opinion, maybe it’s better just to refer to it than cutting and pasting it all into your own note.
It’s also true that sometimes a really nice synopsis, a way to get access to the deeper story, can be very powerful, and help prevent us from missing something critical to a patient’s health.
Perhaps this is where artificial intelligence (AI) can really help us in healthcare — synthesizing massive amounts of data and telling stories, the true story of a patient, in a way that we can wrap our heads around, to make sure we don’t miss the forest for the trees.
In the past week or so we’ve started to hear rumblings of looming problems with AI, fears of it getting out of hand, taking over, wiping out all of humanity. But I remain hopeful that if we learn how to harness it well, it could prove to be invaluable in healthcare, maybe more so than for almost any other field.
Cutting and pasting everything that’s ever happened to a patient into a note used to be a way that we were able to bill for complexity, but now it just seems like an effort in redundancy and insanity.
My hope is that we can start to use these incredibly smart tools to dive into the chart, to ferret out the details, to make sure we don’t miss anything, to broaden our differential and narrow our scope of vision, always focusing on the best thing for the patient.
What are we missing, what else could we do here, how will we know we’re heading down the right path, and how can we learn when we’re not.
Can anyone out there honestly tell me that when they open up a note and are confronted with page after page of old office visits copied forward, that you really read through them all again, synthesize them, use them to make a better decision for today?
Or do we all just skip to the end, avoiding that long journey that, more often than not, takes us nowhere? Certainly not to where we want to be.
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