乌鸦传媒

Several weeks ago, a patient of mine was admitted to the hospital.

Reading through the admission notes, from the triage by the emergency department (ED) through the admitting team, I unfortunately was left a little confused, not sure what was going on.

This particular patient has a long list of complex medical problems, and recently has been undergoing intensive immune-suppressive chemotherapy for a malignancy which had been stable for some time but recently took a turn for the worse. In the days after an outpatient surgical procedure, they apparently became confused and profoundly weak, with waxing and waning altered mental status and shaking chills at home.

All of the notes were long compilations, cutting and pasting from the patient's past medical history, surgical history, and the like, all of which was available in the chart. Imported into the note were their vital signs at ED triage, a long templated physical examination that was not very enlightening, then every lab and imaging test that had been done both in the weeks before the admission and in the emergency department that day. Because the patient was apparently too sick to be sent home, the decision was made to admit them.

What followed in the admission notes was some sort of templated text that was apparently being used to justify the admission. "Reason(s) for admission: to evaluate for and/or treat potential life, organ system, or functional disability threatening illness or injury." Really, that's what they thought was going on? I could have told them that, and I wasn't even there.

Did they think it was a stroke, seizure, heart attack, sepsis, acute adrenal insufficiency, thyroid storm? What?!? And what's with the "evaluate and/or treat" -- is it possible that we may evaluate and then withhold treatment?

Apparently gone are the days when a progress note -- whether it's in the ED or for the general medicine floors, the ICU, or the outpatient world -- was something that was crafted to capture what was happening with a patient that led to this change in status requiring a new intervention. This intervention could be admission to the hospital, intubation, pressors, antibiotics, surgery, or even just ongoing management of their chronic medical problems.

But for this patient, at the end of reading this enormous note that was written on their admission, I really didn't know what their status was, what everyone was thinking, or what they were planning to do.

So many (so, so many) years ago when I was an intern, one of the hateful jobs we had was to dictate discharge summaries on the hematology/oncology service after patients went home. At the end of the week, we were parked in a small airless windowless room in the basement of the hospital, the dreaded medical records dictation office, and an enormous stack of paper charts was left with our name on it, comprising the patients we had admitted and discharged from the service that week.

Our job, according to the attendings who tasked us with this drudgery, was to essentially reread the entire discharge summary from their previous admission as well as the current admission note, and then summarize every lab, imaging test, treatment, and other intervention that had happened during the hospital stay. Finally, we had to summarize the entire hospital course, essentially regurgitating the entire chart and tacking it on to what had already existed before. As far as I could tell, this never really created anything of much use to anybody.

In Internal Medicine, our greatest mentors tried to instill in us the benefit of narrative, of painting a picture. The idea was that someone could read your notes and really get a sense of what was going on with a particular patient, what you thought was happening, what your differential diagnosis was, and what you planned to do about it.

These days notes are templated, with the ever-popular hashtag substituting for a thoughtful assessment and plan -- for example:

• #Hypertension
• BP 150/90
• Increase amlodipine

Nothing about why the patient's blood pressure was high or whether they were taking their medicines. Was it possible they couldn't afford them, that the side effects were intolerable, that they had an implicit fear of taking prescription medicines, that they didn't trust us, or that they skipped the medicine that day to see if perhaps their blood pressure wasn't really that high?

So much goes into a patient's medical history that we need to glean, tease out, and discover. Summarizing and simplifying everything down to hashtags and templated items like "10+ point review of systems negative except as above" and "HEENT normocephalic atraumatic," and listing the voluminous data that is available for everybody to see in the same electronic medical record, seems like a waste.

Maybe someday we'll be able to get back to having our notes just be a discussion of what we thought was going on and what we, along with the patient in a model of shared medical decision-making, decided to do about it.

I'm certain that most people don't read these notes (probably including mine) saying that the radiology report is right there in the radiology section of the electronic medical record, and their CBC, electrolytes, liver function tests, and blood cultures are all right there as well.

Sure, it's nice to refer to those test results, to highlight the important positives and negatives that support or refute a particular hypothesis, to bring the relevant things into your notes if it helps prove your point, if it helps illustrate why you're moving down one diagnostic pathway instead of another, but just cutting and pasting everything into the notes does nobody any good.

Not the next person to read the chart, not the patient, and probably not anybody else for that matter.

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