Storytelling in the Medical Record

Ryan Ames, OD, MBA

InSight Eye Care, Oshkosh, WI

A medical record is intended to be an accurate and complete legal document describing a single patient’s medical history, exam findings, and treatment plan by a provider. We, as the providers, need to understand that this document is more than just a means for us to track what we did and a way to get reimbursed. I often speak to colleagues who will complain how medical record documentation is an obstacle to good patient care. I know they are not saying that we shouldn’t have to keep records, as all doctors know the value of documenting the care. What they seem to be saying is that they feel some of the documentation is not valuable, and they are just doing it so they don’t get in trouble. Or the other side is that they don’t follow the rules at all and are just hoping they don’t get audited.

Through the hundreds of charts I review per month, I see the extremes in documentation. From the verbally verbose to those who apparently think less-is-more. A happy marriage of these philosophies is likely the best option. I like to think that brevity is appreciated, but completeness is mandatory. This hybrid of documentation can be considered the SparkNotes (or if you are a little more senior, the Cliff Notes) of medical record documentation. This type of documentation gets to the point without superfluous information. When another doctor looks over your documentation, they should be able to quickly identify why the patient presented (exposition), what you found (plot), and what you did about it (resolution).

In many charts, I find a great plot (exam), but I can’t find why the story started or how it ended…just a bunch of test results. By looking at the exam notes, I can probably guess the patient came in for a glaucoma check because the IOPs were slightly elevated and asymmetric. Plus, I found an Rx for latanoprost, but there is often no mention of whether this is a new diagnosis, a stable patient, or someone who is out of control. Those vital details to the story are crucial to our understanding. Not only do they help complete the story, but they are necessary to provide quality patient care. A complete medical record is more important to good patient care than any fancy new instrument in the office. Test results mean nothing out of context. The reason-for-visit and history should introduce you to the story’s antagonist (perhaps glaucoma), protagonist (latanoprost and prior SLT), setting (a 84 y/o WF with HTN), and anything else we need to know to understand the state of the patient. Next, we should find the exam which contains elements of the plot. Here we should discover whether the latanoprost is working or if the antagonist, I mean glaucoma, has mortally wounded our heroine (the optic nerve). Finally, in our plan-of-care, we learn if the protagonist has defeated his foe or if he is going to assemble a new army (add timolol/brimonidine combo) and fight another day!

If we do a poor job filling in anyone of these parts of the story, the reader is left wondering how the full story unfolded. Remember what I said in the very beginning, brevity is appreciated, but completeness is mandatory. Simply stating within the RFV, “IOP check, started latanoprost 1 mo. prior, Hx of SLT x 2 yrs,” gives you a great background for the purpose of the visit. This is followed by the exam which will contain the findings (IOP, C/D, VA’s). And then your Plan of Care should put all the findings together and state what the next step is going to be. As brief as, “IOP improved to goal of range of 14 mmHg OU. Cont. latanoprost 1 GT QHS OU. RTC 6 mo. for IOP check, RNFL OCT, 24-2, and DFE.” This ends the story by wrapping up the problem and nicely introduces how the sequel (next exam) will start.

The purpose of thinking of the exam’s documentation as a story is to understand its purpose. This document is intended to capture the state of the patient today, and the care with which they were provided. Another eye doctor should be able to review that day’s chart and understand what was going on and what happened. To check your storytelling ability, look at a random chart from your files. Without knowing the patient, would you be able to know the basics of what was going on? Or would you need to flip through several other charts to understand the picture? You certainly don’t need to rehash every event of the patient’s history in every chart, or re-document every treatment plan ever given. But you should be able to determine the current state of the patient’s condition, what the current treatment and findings are, and finally what the next step is going to be.

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