Help keep this newsletter free by visiting our sponsor below:

Native path has made a spectacular & delicious 100% grain-FREE granola to satisfy your cravings. Shop now!

“No no no…you don’t have glass in your lungs. That’s just a term used to describe some haziness on the CT scan.”

That was my first experience with open charts - a patient who was extremely distressed by the words “ground glass” on a CT and who, despite my best efforts, was having quite the difficult time understanding that she did NOT have glass in her lungs.

It wasn’t a good first impression with open notes.

But since then, many of my fears have not come to fruition.

It has, however, made me consider how we should change some of the language we have historically used in medicine. Moreso, instead of changing the language…do we still need to use that language at all?

First, with every example, you should ask yourself, “Do I NEED to include this in my note? Is this clinically relevant?”

If the answer is yes, then how can I describe it objectively?

Let’s look at some common examples…

1. Unfortunate - “This an unfortunate 81-year-old…” I cannot think of any reason this is clinically relevant. I’ve never used this language and it should be removed from our habitual vocabulary.

2. Poor historian - This could be its own newsletter issue, but patients are not historians. It’s our job to gather a story from all the resources available to us and tell the story. Alternative language might be “Patient had difficulty recalling specific details and timelines related to their symptoms and medical history. Therefore, additional information was obtained by reviewing the medical record, speaking to ER staff and the patient's wife.”

3. Frequent flyer - State the facts, if necessary. “This is the patient’s 8th visit to the ER in the last 30 days.” This is non-judgmental and communicates the pertinent facts to the reader. Maybe the patient is manipulating the health system? Or maybe they have an unrecognized condition that needs further evaluation.

4. Morbid Obesity - No, we can’t stop documenting obesity completely as some suggest. It’s a medical condition that not only has major impacts on a patient’s health and other comorbidities, but also significant coding considerations. With that said, in order of potential offensiveness, likely “Morbid” > “Severe”> “Class 3”.

   • Class 1: BMI of 30 to <35

   • Class 2: BMI of 35 to <40

   • Class 3: BMI of >40

   Some have asked if they can simply document the BMI. This would not satisfy the coding responsibilities. You must specify “obesity” and the severity. Here’s a brief article on the coding, with links to articles re: patient stigma.

5. Non-compliant - Describe the how and the why. How are they taking their medications? And why? Example: “Patient hasn’t taken Lisinopril in 3 months as she’s been unable to get a new prescription due to issues getting transportation to her PCP’s office” or “Patient stopped taking Lisinopril as she didn’t think she needed it because her blood pressure was controlled.” Instead of saying “noncompliant” and moving on, this will force you to get to the underlying issue and provide better care.

6. Disheveled / Unkempt - Be objective. Describe what you are seeing. “Patient’s hair appears unwashed and not recently combed nor styled. Facial hair is grown out, appearing uneven in places. He has patches of dirt or dried sweat on his face as well as minor skin irritations on his face and arms. His clothes are soiled with noticeable stains and wrinkles.” This is communicating what you are seeing without judgement.

7. Older than stated age - As an internist, the answer to “does this need to be documented” is typically “no” for me - It’s not that impactful in the overall clinical picture. For pediatricians, however, this may be significantly more appropriate and not offensive at all. But, if you deem necessary, again, be objective: “Pronounced wrinkles, several facial sunspots, skin elasticity changes” etc.

8. Challenging patient - I’ve discussed this with a medical malpractice lawyer. What if a patient is consistently rude or you had a negative interaction with them? In brief, he recommended simply describing the events fact by fact. “The patient frequently interjected during the discussion of the diagnosis, expressed dissatisfaction with the care using strong language at an elevated volume and displayed physical signs of frustration and ultimately declined to engage in further conversation at that time.” You could consider using ChatGPT to help you re-word in a professional, “lawyer-esque” way.

But I’m a doctor. I’m supposed to give my assessment…

Remember the objective section, of which the physical exam exists, is meant to be…objective. But, the assessment / plan section, is meant to give your…assessment.

As a CDI advisor, I must remind you that if your assessment is that the patient is cachectic and you described cachexia in your physical exam, it’s important to call it “cachexia.”

That’s way too many words…

Yes, “disheveled” is much shorter than the description. But the bigger issue is we’re not in the habit of writing such descriptions. As we get more experience, we’ll rattle off these descriptions quicker. Ask a dermatologist - as residents they climb this learning curve quickly with rash descriptions.

There are other concerns and considerations with open notes…

1. Did I recall and tell the patient’s story accurately? I discussed that here: What many get wrong about the HPI (beehiiv.com)

2. How do I balance complexity with clarity? This is an area of debate. Should our notes, particularly the assessment / plan, be meant for other medical professionals or the patient? It’s recommended that language for the general public be at an 8th-grade level. Is that realistic for an A/P? Heck, I’d love for some specialist’s notes, such as oncology and ophthalmology, to be on a level where I, a general internist, can understand it! - let alone a patient!

3. Will I spend excessive time explaining distressing or misinterpreted terms in reports? Like my opening example, patients can receive results without interpretation, leading to distress and time explaining these terms. I have not personally found this to be as common as I initially suspected. However, I’ve heard from many oncologists that this is a particular issue with after-hour results. Patients receive results without the benefit of having an oncologist explain to them the next steps, prognosis, or that the results are not as concerning as they seem, etc - leading to days of stress and anxiety.

4. Will there be increased litigation as a result of open notes? I asked Eric, author of The Expert Witness Newsletter, if he’s found this to be the case. “Open notes” came into law April of 2021. “Short answer is no. It’s too recent of a change to see it any cases. Most lawsuits take a year to file and then another 2 - 3 years for the details to get into the court record.”

5. Could my differential cause anxiety? Differentials mentioned in the note, such as malignancy, that weren’t mentioned to the patient in-person may be anxiety-inducing.

6. Will the patient see results before I do? This has been the biggest impact I’ve seen. It’s common that labs / reports have not resulted by the time of my pre-rounding (when I’m at a computer). Then, I’m unaware they’ve resulted during my bedside rounding, and the patient mentions the result during my visit. It’s led me to making interpretations or answering questions that I’ve not had time to prepare. Fortunately, EPIC has a mobile-phone app of which I’ve tried to use more often when I’m on the floor. But, I still get some surprises.

So, in summary, consider the audience of your notes - one of which is the patient. Ask yourself WHY you are documenting what you are documenting. If you deem it’s necessary, be objective with the facts. Then, give your medical assessment in your A/P when necessary.

That’s all for now. I hope that was helpful.

Thanks to Yuby, whose question inspired this issue!

Cheers,

Robert

When you’re ready, there are two ways I can help you:

1. If you’re a resident, med student, NP, PA or fellow and want to have the tools to spend less time writing notes, help you stay organized, impress your attendings, and be prepared for post-graduation with an affordable 1.5 hour video course:

   → Check out The Resident Guide to Clinical Documentation

2. Promote yourself, your business, your conference, etc to 3,852+ subscribers by sponsoring this newsletter.

If you were forwarded this newsletter and would like to subscribe: