“When the patient fainted, her eyes rolled around the room”: How to make medical charting clear and accurate.

Recently Dr. Maurice Bernstein from The Keck School of Medicine, at University of Southern California, wrote into the listserve DR ED with this intriguing question:

I find many first and second year medical students present their patient write-ups for their instructor’s review with errors both typographical but also errors in presentation that makes statements seriously ambiguous.  I tell my students to read what they have written and then re-read again as an individual who knows nothing about the patient.  In addition, I have presented them with a list of “comic” but presumably also realistic medical charting errors. 

Is there something more I can do to teach the students to be more attentive particularly later when what they write for the record has greater clinical significance for the patient than a first or second year student?

MEDICAL CHARTING ERRORS 

  • By the time he was admitted, his rapid heart had stopped, and he was feeling better.
  • Patient has chest pain if she lies on her left side for over a year.
  • On the second day the knee was better and on the third day it had completely disappeared.
  • She has had no rigors or shaking chills, but her husband said she was very hot in bed last night.
  • The patient has been depressed ever since she began seeing me in 1986.
  • Patient was released to outpatient department without dressing.I have suggested that he loosen his pants before standing, and then when he stands with the help of his wife, they should fall to the floor.
  • The patient is tearful and crying constantly. She also appears to be depressed.
  • Discharge status: Alive but without permission.
  • The patient will need disposition, and therefore we will get Dr. Shapiro to dispose of him.
  • Healthy appearing decrepit 67 year old male, mentally alert, but forgetful.
  • The patient refused an autopsy.
  • The patient has no past history of suicides.
  • The patient expired on the floor uneventfully.
  • Patient has left his white blood cells at another hospital.
  • The patient’s past medical history has been remarkably insignificant with only a 45 pound weight gain in the past three days.help pile of records
  • She slipped on the ice and apparently her legs went in separate directions in early January.
  • The patient experienced sudden onset of severe shortness of breath with a picture of acute pulmonary edema at home while having sex which gradually deteriorated in the emergency room.
  • The patient had waffles for breakfast and anorexia for lunch.
  • Between you and me, we ought to be able to get this lady pregnant.
  • The patient was in his usual state of good health until his airplane ran out of gas and crashed.
  • She is numb from her toes down.
  • While in the ER, she was examined, X-rated and sent home.
  • The skin was moist and dry.
  • Occasional, constant, infrequent headaches.
  • Coming from New York, this man has no children.
  • Patient was alert and unresponsive.
  • When she fainted, her eyes rolled around the room.

After I finished giggling, I started to think…this is a problem with an educational and literacy component. What does educational pedagogy teach us to assist with this issue?

So here are a few ideas from my experience as an educator —these could be potential teaching strategies.   BTW, don’t do all of these…:)  1-3 should make some impact.

  1.  Work with this list: Give students the charting errors list above—it will be a good teaching moment for them and help them see how awful some of their errors could be.  You could ask them in partners (to share the fun) to correct the errors as best they can, reading between the lines, or to create a set of questions that would help clarify some of them. In other words, put them in the role of the teacher.
  1. Think of busy times: Ask students to list the times they may be most busy in a clinical setting.  This list should be posted for them to remind them that these are the times they need to slow down and focus most, ironically, on their writing.

    Busy? Slow down.

    Busy? Slow down.

  1.  Writing and recall for purpose:
think of the patient

Think of the patient.

a. Ask students to generate a list of purposes for charting; writing for purpose is a strong strategy for improving writing. I’m hopeful some of the purposes will be:  pay respect to the patient’s illness and the patient (patient-centred care), safe care for handover and for others reading the chart, legal documents for liability, etc.

b. Then, ask students to keep these in mind as they chart.  Mindful exercises could include using a symbol to associate with each purpose—drawing it, literally, or drawing it clearly in their minds, using a key word to help them recall, or if they tend to associate sounds, or colours with concepts, they could do that.

handover

Here’s my image for handover, for example. Don’t drop the baton.

Ask students pause for exactly 3 seconds prior to charting to collect their mind, to steady their writing and to recall these purposes.  Actually 3 seconds is like taking a deep breath.

NOTE:  thinking about the target audience, as in “Who potentially is going to read this?” can also achieve a impact.

  1.  Simulated chart exercise: Give students a simulated case and a chart exercise and a very stringent time limit.  Ask them to work in pairs and edit each other’s notes after the exercise.  OR, use “Pass It On” strategy, where students affix a nickname, or number to their work (to preserve anonymity and dignity :)) and pass the chart along to the left, so that at least 4 people get to weigh in on it with feedback.  NOTE:  this is also a good exercise in how to give feedback—warn them against being sarcastic, or harsh—their time will come! Ask students to practice good feedback techniques:  being specific, offering suggestions, avoiding judgements of the person, focusing on the writing, etc.
  1. Read the chart entry aloud.  Ask students to practice this.  This takes approximately 6 seconds at most (depending on the chart).  Reading a piece of writing aloud is another recommended editing strategy practiced by writers.

    each-word

    Read it out loud.

  1. Be careful with the use of abbreviations and acronyms which are not commonly used or can be ambiguous in interpretation. For their patient write ups, except for absolutely classic clinical acronyms such as C for “centigrade” or BP for “blood pressure”, the words should be written out such as “myocardial infarction” and NOT “MI” since MI could also represent “mitral insufficiency”. You could teach students that if any obscure acronym is to be used later on in the text, in its first use, the full expression should be written then followed in parentheses with the acronym noted.  Unfortunately, also, many acronyms or abbreviations in medical use are not written in a standardized manner between one institution and another and this can also lead to errors if not recognized. Bottom line: avoid or be really careful. (Thanks to Dr. Maurice Bernstein for this tip.)
  1. Avoid General statements: I got this feedback to a student from a nursing blog article by Katie Morales called 17 Tips to Improve Your Nursing Documentation.

Teacher: For example, you wrote “Dr. Smith called.” Did you mean: you called and are waiting for a return phone call; physician called nurse; or nurse called and spoke to physician?”  A better option is “MD

EmergencyResidencyStudents

Work with a partner and correct.

paged, assessment findings discussed, and no additional orders at this time.” 

 

Similar to strategy 1, I would give the students general statements where they can figure out what’s going on, similar to Ms. Morales’ example.  I’d work through one or two on the screen with the students first.

 

  1.  Checklist of common charting errors:  Making a checklist of these for students is helpful and having it handy when they are charting is also helpful (make it pocket-sized).  Checklists are a helpful literacy tool—no reason they shouldn’t work with charting literacy:  Here are errors from a good module RN.com has: Professional Documentation:  Safe Effective Legal.  (Students could make it into an alpha list or an acronym list). Most of these would be applicable for physicians as well as nurses. (You might want to make them positive: e.g. “Record Pertinent Health or Drug Information.”)

3d small person makes a tick in cell. 3d image. White background.

Common charting mistakes to avoid include the following:

  1. Failing to record pertinent health or drug information
  2. Failing to record nursing actions
  3. Failing to record that medications have been given
  4. Recording in the wrong patient’s medical record
  5. Failing to document a discontinued medication
  6. Failing to record drug reactions or changes in the patient’s condition
  7. Transcribing orders improperly or transcribing improper orders
  8. Writing illegible or incomplete records
from:  Nurses Service Organization, 2008, pp. 4 – 5

From a medical standpoint: Take a look at: Top 10 documentation error pitfalls: from Wisconsin Medical Society: 2008.

  1.  Teach with examples.  Show students excellent examples of charting to give them the necessary language for their work.  Give them criteria that facilitate effective charting.  Look back at the RN.com for some great criteria! As well CMA (Canadian Medical Association) has a good module called Medical Records Management with 31 (!) criteria for effective charting.

NOTE:  I’ve never met anyone who can keep to a 31 point checklist, but the criteria cited are all really important, so…perhaps students can check off the ones they think they do well already, and star the ones they need to work on.  A sampling of their work in clerkship (observation and feedback—still necessary) will demonstrate their self-assessment skills as well as how well they record.

10.  For senior clerks and residents: The  nursing module, RN.com: Professional Documentation:  Safe Effective Legal, has a list of situations that are classified as high stakes documentation.  This would be critical information for senior clerks and residents. (You’ll see that I’m citing nursing education here a lot: Nurse Researchers and Nurse Educators do excellent work on health and education.)

charts patient safety handover

For Residents and Senior Clerks

In Ratnapalan et al, Charting Errors in a Teaching Hospital, these suggestions for residency are included:

  • Many training programs recognize that residents in their first month may have charting errors and have put in place orientation programs, increased supervision from senior residents and staff, and a more thorough review of the notes that are written by new residents.
  • The ED at the Hospital for Sick Children is the only dedicated pediatric emergency department in the city of Toronto, and 380 to 400 trainees rotate through the department annually. Currently, there are orientation packages, orientation sessions, and a Web-based orientation available for trainees to teach accurate charting of emergency records.
  • The orientation package is a large binder with complete instructions on goals and expectations, codes of conduct, medical record keeping, handling of specimens, procedures, and academic activities.

Glad to get feedback on these strategies, and add to the list! What do you suggest?

send us your suggestions

5 Responses to “When the patient fainted, her eyes rolled around the room”: How to make medical charting clear and accurate.

  1. Kanji Nakatsu says:

    Tony:

    You couldn’t make up these lines. If the potential outcomes were not serious and important, they would be hilarious.

    Thanks,
    Kanji

    • Hi Kanji: I know exactly what you mean–almost feel guilty laughing! The point is that we have to help our learners be more aware of the serious impact of charting. Thanks for your comment.
      Sheila

  2. David Walker says:

    A corollary is the use of language that makes sense to us but not our patients; Mrs Jones, you have “failed” the first round of chemo (nothing like failure to perform up to expectations on top of cancer – actually is was us that failed); Miss Smith has “thrown” an embolus (right handed?) and she already had a “thrill”. And nearly everyone has a “complaint” (those complainers) but “denies” (on the witness stand) being short of breath. Much of what our patients tell us we describe as “insignificant”. When all else fails, we “review” our patients’ systems. When the CPSO “reviews” our practice, we docs get very nervous. No wonder we don’t want our patients to see their charts.

    • Hi David: Excellent addition to the issues. Successful communication is all about subsuming our own assumptions to ensure the listener gets the message. Thanks for these great examples!
      Sheila

  3. Stephen Zimmer says:

    I remember when the nurse in my office left a sticky note on a patient ‘s chart to let me know why he was being seen. It was for a ‘follow up check up’ unfortunately she used a short form..f/u ck up. (When I told him of the nurse’s diagnosis, he got quite a kick out of it)

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