Hitting a Nerve

Now missing in EHR charts: a good impression


I’ve previously written about “the monster note,” a creation of autofilled blanks with vital signs and test results that tells you very little about what’s really going on.

Recently, while on call, I discovered a new problem: the lack of a decent impression.

I was covering for another doctor, and a cardiologist rounding at a rehab center called to see if he could anticoagulate a recently discharged patient. It was certainly a reasonable question.

A doctor holds a chart copyright BrianAJackson/Thinkstock
Not knowing the case, I logged in from home (a definite plus of moderns systems) and tried to figure out the plan from the chart.

Unfortunately, not much was there. Most notes were the usual mishmash of test results, vital signs, and medication lists, with very little about the patient. So I scrolled down to the impressions to find out what the plan was.

Sadly, that area (which to me is the most critical part of a note) was also devoid of anything useful. Hoping for something like “embolic stroke, hoping to anticoagulate in future,” I instead found things like “To SNF or rehab soon” or “case discussed with family” as the entire impression and plan. That tells me nothing. The only note I found that had some sort of assessment and plan was the initial consult, which was done before any test results were in.

This seems to be the current state of things. Notes that actually give you some idea of the thinking and plan have become an endangered species. This helps no one, as most of us rely on other doctors’ notes to coordinate and plan care. While some of this is done through talking or texts, those things aren’t in the chart. So even though the doctors involved may have a good idea of what they’re doing (and I certainly hope they do), an outsider doesn’t.

In my opinion, that does nothing to improve patient care. I suppose it works if the same doctors are involved each day, but that’s not how American hospital medicine is any more. Hospitalists rotate in and out every few days and (as in my case) others cover call on nights, weekends, and holidays.

Dr. Allan M. Block, a neurologist is Scottsdale, Ariz.

Dr. Allan M. Block

This isn’t the EHR’s fault. It’s just a tool. It’s how humans use it that becomes the problem. At this point, I think this lack of information in the notes is a bigger issue than the previous challenge of trying to decipher another doctor’s handwriting.

It’s also a gateway to legal challenges. A malpractice lawyer once told me that notes should be written so that if you have to read it 5 years later, you can get a pretty good idea of what your thinking was. If the details of the plan were carried in your head, or were in conversations with other doctors, those things aren’t going to help you. The written record is everything. If the issues these notes pose to patient care don’t worry you, maybe that thought should.

Back to my patient: It took me about 15-20 minutes of skimming through the note to find the answer I needed. And it wasn’t in any of the doctors’ notes at all.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

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