Poor, illegible entries in medical notes can cost lives

I was present recently at a meeting between representatives of a hospital and the relatives of a recently deceased patient.  The death had been the subject of an inquiry and in preparation for the inquest, the family had been given copies of the medical notes.  A significant part of the meeting was spent, explaining the meaning and significance of various entries in the notes. Embarrassingly,  some handwritten entries in these medical notes could not be interpreted by the medical/nursing staff who were present.

This episode got me thinking – apart from the content of what we write, how many of us pause to think about the potential readers of what we are writing? Potentially these could be many – doctors, nurses, other healthcare professionals, patients, their relatives and even lawyers. How much time, as educators, do we spend teaching trainee doctors how to write in medical notes. I know that I was never formally taught how to write in notes – you just got on and did it. One has always made the assumption that if someone has the medical knowledge to effectively assess a patient, then composing a medical entry is a piece of cake!

Wrong.

Poor, often illegible entries in medical notes and for that matter in drug prescription cards must, like all examples of poor communication, be responsible globally for countless deaths and cost healthcare providers billions of dollars a year in lawsuits. This is certainly the case in parts of the health service in England (both public and private) where the primitive mediocre landscape of healthcare communication has not changed in probably a century. There have been unbelievable advances in medicine and surgery over the past 30 years let alone a hundred. Life expectancy figures are increasing exponentially – and yet the fact that healthcare communication is stuck in the nineteenth century baffles me!

I was heartened recently to read an article in the British Medical Journal entitled “Welcome to the Century of the Patient. In this article, Ann Gulland, a freelance journalist described the outcome of a global seminar that took place in December 2010 in the Austrian Alpine city of Salzburg. The topic was shared decision making and at the end of the conference a number of individuals from all over the globe signed the so-called Salzburg statement.  Shared decision-making or Participatory medicine is slowly taking over from the old paternalism and will influence development of medicine in general over the next few years/decades. In recent years bodies such as the Society for Participatory Medicine and the Foundation for Informed Medical Decision Making have been set up in the US. Health policy makers on both sides of the Atlantic increasingly take heed of this agenda.

The shape of Medical Notes or more likely the electronic health record will be influenced by shared decision making with the patient. Leaders in shared decision-making suggest that systems are in place for patients to have full and unhindered access to their medical records. In the not too distant future, all healthcare workers will have to take heed of the fact that the patient or their relatives will be regular consumers of their input. This will lead to a much-needed bottom up reform of medical notes. The sooner the better.

Norman Briffa is a consultant cardiac surgeon practicing in Sheffield, Yorkshire, England, blogs at Thinking Allowed – Conversation with a Chestcracker and can be found on Twitter @chestcracker

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