The 21st Century Cures Act allowed patients to view their medical records, including the entire emergency department documentation. This means that patients can read anything written in a doctor’s emergency note.
And that means chart etiquette has a new importance in emergency medicine. Comments that physicians would typically place in the medical record or have been trained to document (some of which is subtle or normal medical language) can be upsetting to a patient or family member who accesses a medical record during or after a visit. Remember that patients and people they share their records with can see your grading verbatim. With this in mind, it is important to remember some tips when creating a chart.
The note can be viewed by multiple non-clinical readers – the patient, family members, and others. Patients sometimes see the note as a personal description of themselves at a time when they were ill, vulnerable, and often in a high emotional state. We need to rethink how we document all facets of the record, including our description of patients and family members in history, review, and medical decision-making.
Some aspects of ED documentation have been classically taught and used for objectivity and medico-legal protection, so we must now consider the implications of these statements for the patient and family as they read our notes. Offensive or inappropriate grading may cause the patient and family to have a negative image of the care received and possibly put the physician at undue risk.
Avoid emotions and labels
Document objectively and unemotionally, and keep your tone flat and consistent throughout your notation. When possible, take the time to create personalization and, when appropriate, compliment the patient and family (“Mr. Smith is here today with his wife, who helps take care of him.”)
Document your full, physical story, but be sure to remain factual and objective at all times. Do not document parts of the history and physical exam that you did not complete, such as a full systems exam if not completed or parts of an exam that were not completed. not take place.
Be careful not to overuse the models or create oddities in the record that could confuse or create conflict (eg, a 12-month-old patient does not have suicidal thoughts). Unless necessary, try to avoid excessive and extreme adjectives that might worry downstream readers (eg, severe).
It is also wise not to label patients or their families in the record using terms such as drug seeker or describing them as anxious. Do not use pejorative terms or negative connotations to describe patients, family members, or their behavior, including some terms classically taught and used in medical literature, such as obese or manipulative. Instead, use a high BMI or objectively describe the behavior.
Do not use inflammatory terms in the record that could upset patients, such as saying a patient is seeking medication, a mother is impatient for results, or a patient appears to have a side gain. Do not write down your personal opinions about patients, families, consultants, or others in the note.
Consultants and Operations
It is extremely important not to document conflicts with nurses, consultants, or other providers in the emergency department record (e.g., “I disagree with the cardiologist regarding the interpretation of the ECG and the decision to cancel the STEMI code”.) Be careful and tactful if you note delays in care and do not write inflammatory comments. (e.g., “I had to call the surgeon three times before I got a callback, and it took him two hours to see the patient, which delayed care.”)
If you’re documenting a course in time, be tactful and tactful: “Ortho phoned 1000, 1030, and I discussed the case with the orthopedist at 1100 who recommended X.” Do not document operational issues in the table (for example, staffing shortages or hospital capacity issues).
Also consider other places to document operational or professional issues outside of the medical record (eg, the Security Event System), and certainly don’t crack jokes or add humor to your documentation. This can be misinterpreted later. Do not make prejudicial comments or rant in the note.
We’ve always been taught to label cases of sexual assault and domestic violence with the term “alleged,” but that mentality in the literature has changed. Providing fair care to our patients means we believe what they tell us. Avoid using terms like “alleged assault” in the history, medical decision-making, or impression.
Using neutral language removes the appearance that we believe or don’t believe our patients and protects against implicit bias. We do not record or diagnose suspected motor vehicle accidents or suspected chest pain, and we should offer the same confidence to victims of sexual assault and domestic violence.
Words tell the difference, so use objective terms such as “patient reports or statements” instead of “alleged”. The use of words like “alleged” can retraumatize these patients (its literal definition means “said without proof”). Many of us have been told that using the word “alleged” would save doctors and other providers from testifying, but that doesn’t seem to be the case. Prosecutors generally prefer the forensic nurse to testify in sexual assault cases, not the doctor, PA, or advanced practice nurse. One said she had never had a doctor testify on behalf of a victim in her 13 years of prosecuting rape cases.
It is important to note that many victims of sexual assault and domestic violence never file a complaint and, unfortunately, cases are not prosecuted for multiple reasons. Many victims never even go to the emergency department to report their assault or seek treatment. When a victim asks for our help, one of the best cares and medicines we can offer is to listen and believe them. The use of the word “alleged” is contrary to this idea.
None of these ideas are inherent in the training that many of us received on medical documentation. Changes to the 21st Century Cures Act may seem frustrating and time-consuming, but many believe it will lead to lower overall risk and increased transparency for patients and families.
Allowing patients greater access to documentation and an understanding of what was done and why care has decreased their need to seek this clarification from outside sources or other avenues (i.e. litigation). With an open mind, we can view patient access to medical records positively and use the chart to show that we have provided high quality, thorough, personalized patient care, increasing patient satisfaction while reducing risk. for the doctor.
Dr Baskinis an emergency physician at the Cleveland Clinic, quality improvement officer at the Clinic’s Institute of Emergency Services, and assistant professor of emergency medicine at the Cleveland Clinic Lerner College of Medicine. Dr Fertelis Associate Professor of Emergency Medicine, Associate Director of Quality for Regulatory Affairs and Corporate Quality and Safety, and Director of Operations for the Institute of Emergency Services at Cleveland Clinic.