Physicians must reclaim the medical record


acp new logoA guest column by the American College of Physicians, exclusive to

I recently saw a new patient who came to our practice following a lengthy hospitalization. He is in his 80s with a fairly complex medical history typical of many in this age range. Yet, after carefully sifting through my first introduction to this gentleman — a 32-page discharge summary — I was completely unable to glean the circumstances that led to his hospitalization.

Amid the completed tick boxes, auto-populated forms, a recurring list of medical problems, and a printout of every medical and nursing order written and medication administered during his hospital stay, every few pages I found a couple of sentences of text that were clearly propagated from previous entries with either very minor or no changes whatsoever.

However, what was missing in the entire document was the actual “story” of the patient — who he is, the medical burden he suffers and its impact on his life, how he became sick, what we thought was wrong with him, how that understanding and what we did for him evolved over the course of his admission, and perhaps most importantly, what needs to happen next to help return him to his best quality of life. The thought struck me that with the increasing access that patients have to their own medical records, would he even recognize himself in this documentation of his hospitalization?

The nature of how we record our interactions with patients has profoundly changed in recent years, and not necessarily in positive ways. Most attribute this change to introduction of the electronic health record (EHR) which initially promised improved efficiency, legibility, and ability to transfer clinical information effectively across care settings. And while perhaps some of those advantages have come to pass, accompanying the expanded use of the EHR has been an marked shift away from medical documentation’s primary use as a patient care tool to one used for recording information for non-clinical purposes (such as for coding and billing).

Even those aspects of the EHR intended to make our jobs easier, such as templates, check boxes, and the cut-and-paste function, have also caused major changes in the quality and meaningfulness of our medical documentation, often making it discontinuous and less coherent by breaking any narrative into small, discrete, and often repetitive pieces.

Another consequence of this change in documenting our patient interactions is simply the volume of information clinicians are expected to enter that is both daunting and often overwhelming. This has forced clinicians to rush to complete everything required and has now intruded into the actual clinical encounter as physicians feel the need to document in real time in front of patients. And perhaps most destructively, many are spending multiple hours of their own time daily completing documentation, which certainly doesn’t lend itself to physician well-being and is a huge contributing factor to physician burnout.

However, in the midst of what many consider a true crisis in medical documentation, it is helpful to take a step back and reflect on why writing about our patients has always been a key clinical skill and one that remains important regardless of the evolution of the platform on which it occurs.

A primary goal of medical documentation has always been to provide an opportunity to understand our patient’s story. Writing about patients requires directed questioning and focused listening to capture the key components needed to develop a deeper and compelling understanding of who they are as a person. When coupled with the physical examination, the resulting narrative weaves together the physical and biographical aspects of the patient and provides the invaluable context in which medical care is being provided.

Although patient management may ultimately be driven by data, it is often the story more than anything else that determines how well a patient is cared for. The importance of this is why so much time and effort is devoted to teaching patient interviewing, physical examination, and documentation skills early in medical school before students even start seeing patients. And the importance of this ability to capture the story of our patients and use it in the patient care process is not diminished once we enter active and busy practice.

Medical documentation also offers the opportunity to reflectively think about our patients. Creating effective medical notes requires integration and synthesis of patient information as we formulate an assessment and plan. After all, being able to gather, analyze, reflect upon, and act on clinical information is one of the distinguishing aspects of medical practice that separates us from the more purely technical parts of medicine. The medical note can be an important way of using critical thinking to tie together the otherwise unconnected fragments of clinical information in a coherent manner.

And medical documentation is an essential way of communicating with others in the patient care process. I frequently emphasize to the trainees with whom I work that their ability to convey their clinical thinking around a patient is what ensures continuity and the quality of care to others who will be seeing the patient but may not know them as well. Failure to do this is exemplified in my patient’s case in which through 32 pages of documentation I have no clue as to what those caring for him thought or how to link what was done for him in the hospital with what he needs over the long term.

As medical documentation has evolved in the digital age, we’ve clearly lost focus on these primary reasons for recording our encounters with patients. I hear frequently from colleagues who complain that we didn’t train to become data entry specialists – we trained to take care of the medical needs of our fellow human beings, and that this requires more than what our current documentation systems allow.

Although no one is advocating a return to lengthy, handwritten notes as the primary way we record our interactions with patients, there must be a more effective and healthier alternative to our current system. This is why multiple professional societies and others are working so hard to decrease the burden of documentation now required, which is a good place to start.

However, as physicians we need to continue our collective efforts to reclaim the medical record and return it to its originally intended purpose as a meaningful tool in actually caring for patients.

Philip A. Masters is vice-president, Membership and International Programs, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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