If You Find It, You Own It

(Written in 2009 and even more pertinent today with all the mandated fluff in medical office notes)

Working with students always makes you think about why you do certain things the way you do them and why you may feel more strongly about some things than others.

Today, in talking with one of my students about how to do a history and physical exam, I admitted for the first time something that has plagued me for most of my career:

As an intern in Sweden during one of my first surgical subspecialty rotations I had to do the admissions of patients who came to the hospital the afternoon before elective procedures. Those were the days when nobody had to get up before the birds in order to check into the hospital at seven a.m. for same-day major operations and procedures.

I remember dutifully documenting the history of a man who mentioned in passing as I went through a Review of Systems that his bowel movements were getting narrower in diameter – a possible sign of colon cancer.

My attending physician was the head of his subspecialty department and a very busy surgeon. I must have had five or six admissions to do that afternoon.

I remember thinking that this patient’s altered bowel movements were significant and needed some type of follow-up. The attending was not on the ward, but doing a clinic at the other end of the hospital and the resident was seeing patients in the emergency room, so with several more admissions to take care of, I did what I thought was the best I could do and carefully documented the patients symptoms for the attending physician to read and presumably act on the next day before surgery.

The next morning when I arrived at the hospital he had already been in the O.R. for almost an hour and I didn’t get around to asking what he thought we should do about the patient, whose name I didn’t even remember by then.

It could not have been long afterward that I realized that attending physicians with busy surgical or clinic schedules don’t necessarily read their interns’ charts closely enough to find pearls of information deep inside paragraphs that document mostly normal findings.

I realized today why I feel so strongly about making clinical notes clearly distinguish between normal and abnormal findings. This has become an even bigger challenge with the seemingly ever-increasing need, at least in my adopted homeland, to document even perfectly normal exams in great detail for the sake of higher reimbursement and protection from lawsuits.

A macabre example of documentation just for the sake of documentation came to me a couple of years ago in the form of a four page printout of a cardiologist’s office note, which must have involved all of ten minutes of face-to-face time between doctor and patient. Most of the information in the office note was repeated Past, Family and Social History. The exam followed a template, and the Review of Systems had been imported from a patient questionnaire on an optical reader form, similar to ones we used for tests in school – I have seen that particular electronic health record in use.

Deep inside the four page document was a notation that the patient admitted to suicidal and homicidal thoughts. The busy cardiologist didn’t comment on it, and I dare say he never noticed it was there.

Ultimately, whether we are nurses, interns or Board Certified specialists, if we are the first or only ones to know about something important in a patient’s history or physical exam, we own it, at least until someone better suited can take over.