Posted by: notdeaddinosaur | February 20, 2012

Goldilocks Charting

I have a new Nurse Practitioner student precepting with me for the next few months, so I’m once again plunged into the world of the learner. This one’s pretty sharp, but there are still some things we need to work on, as I was reminded when I saw her first effort at documenting a normal physical exam.

Medical charting has always been a balancing act between too little and too much. Family docs as recently as the 70s and possibly 80s could document an entire visit on one line. You don’t have to go back very far, charts from family docs from the 70s and 80s, to find charts with the entire exam documented “WNL” (“Within Normal Limits”; though some claim it means “We Never Looked.”) Clearly that’s too little.

Here’s a student version of what is essentially a normal exam:

TM pearly gray, auditory canals non-inflamed; auditory canals clear, no cerumen
Nares patent, tubinates pink, clear nasal discharge
Oral mucosa and palate pink, good dentition, tonsils pink, no exudate seen
Neck supple, no palpable cervical or supraclavicular nodes, trachea midline, non-palpable thyroid
Lungs CTA bilaterally, no wheezing, crackles
HRR, normal S1/S2, no murmurs, no gallops
Abdomen with +BS in all four quadrants, liver and spleen non-palpable

That’s just half of it. To my eye, it’s a little too much. Here’s how I would document the same exam:

HENT: pearly TMs, throat pink, nose pink/clear
NECK: supple, no nodes
CHEST: lungs clear, cor reg, no m/g
ABD: NABS, soft, non-tender, no mass/megaly

So how do you determine how much is “just right”? Medical documentation has to serve many purposes, including legal, clinical, and payment justification. You must have enough to convince the lawyers that anything that may have gone wrong wasn’t your fault, and, sadly, you need enough to prove you deserve to be paid for the work you did. But as a practical matter, the main day-to-day function of medical documentation is to describe what happened, both to yourself and to any other doctors who may take care of the patient; mostly yourself.

The idea is to keep the “normal” documentation brief and clear enough so that ABNORMALS STAND OUT. Some EMR templates automatically BOLD abnormal findings, mainly by having the normal exam in boilerplate and allowing the physician to free type abnormal findings. By documenting normal exams the same way every time, my eye can quickly pick out abnormalities; a heart murmur, a rash, ankle swelling, bulging red tympanic membranes, etc. But the only way it works is by keeping the normal exam as concise as possible. Not too much, but not too little; just right.

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Responses

  1. As an EMT student I’ve been running into a similar problem with documentation. I’m trying to find the balance between too much and too little. I think or EMS purposes though more is better – to please the lawyers at least.

  2. Heh. I precept learners from MS3s through PGY4s and I see this all the time. Heck, I recognize the change even in myself. When I started as an attending almost two years ago my notes were lengthy, verbose, and rife with positives and negatives. Now they are far shorter and heavily abbreviated. We’re switching to an electronic medical record in a few weeks so I have a feeling I’ll swing back to the verbose side of things until I become more comfortable with the new system.

  3. I find that even within the context of an EMR, some providers are far more verbose than others. There are those who have almost nothing but abbreviations, where their ROS and/or exam looks like computer output (e.g., for heart they write “RRR, S1, S2”, for respiratory they have “CTA”, for abdomen they list “NABS, no HSM”). Others have what’s I’d consider almost too much information, where every possible system is reviewed and/or examined and you’re left wondering why exactly the pt. showed up until you get the dx(es) at the very bottom of the note. You hit it spot on when you said that the key is to be concise. Complete without being overwhelming, useful without being excessive. For a new person to the system the amount of abbreviations seems almost insane, but after while you come to expect them and are surprised to see a note where everything is actually written in full words. I’ve seen both, and each has its value. Personally I think I’d have fallen in between the two extremes had I managed to be the generator of records rather than the coder.

  4. I’m working with an NP student myself, and I find that I love her notes! For the most part, at least.

    Her physical exam documentation may be a bit wordy, but she’ll get more concise with time and as she gets more comfortable with being a practitioner vice a bedside nurse. I can deal with wordy and work with her on leaving out the unnecessary. (Unlike many of the residents she’s working alongside, for whom documenting a single extra word is like pulling teeth!)

    Her lack is in the HPI, where she seems to rely more on the ROS documentation to do the yeoman’s work, and often putting only a single sentence for the present illness, even in some of the more complicated kids. But we’re getting there.

    I was so tickled that she asked me to be one of her clinical preceptors…the only one that she’s working with in the ER. And she’s so excited about what she’s doing. It makes the nights much more enjoyable when she’s there, and I’ve found a renewed interest in teaching because of her.

  5. My guess would be she worked on a hospital floor as an RN, where you chart, chart, chart all the lifelong day to fulfill requirements and to cover your ass. Nurses write notes about everything.

  6. Nice post, keep going

    Thanks
    Prakash
    http://medicalinformationforyou.blogspot.in/


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