The Case Record
Mephistopheles: I’ll wait on you tonight, when you partake Of college gaudy, where the doctors dine; Only—since life, or let’s say death’s at stake— I’ll bring you back, please, a couple of lines to sign. Faust: So, black and white you want? You’ve never heard Good pedant, that a man may keep his word? … A parchment, notwithstanding, signed and sealed, Is bogey fit to make the bravest yield.
—GOETHE (TRANSLATED BY PHILIP WAYNE). FAUST: PART I: THE STUDY (3)
POINTS TO REMEMBER:
The medical record is also a legal document. Never alter it without clearly signing and dating the changes.
Time spent in detailed history-taking and physical examination, even when results are normal, pays rich dividends in a sense of mastery and experience with the range of normal variations.
Introduction
A Note on Modern “Documentation”
At the outset, the student needs to recognize that this chapter concerns the traditional case record, which these days the student may see only when reviewing old charts. There is an increasing tendency for the medical record to be co-opted for many purposes other than patient care: to determine third-party payment (supporting or serving as the rationale for denying a claim); to perform institutional reviews aimed at “utilization review,” “resource management,” or “quality assurance”; or to serve as evidence in malpractice litigation or cases of alleged insurance fraud or other crimes such as the prescription of controlled substances “not in the course of a legitimate medical practice.”
The needs and demands of third parties may so change the medical record that its usefulness in patient care may be greatly degraded (Orient, 1998). One private physician told this author that he essentially prepares two documents every time he writes a letter to a referring physician, one to comply with demands of the third party and one to communicate his analysis of the patient’s case so that it may be understood by another physician.
An honest, accurate, and coherent medical record is essential for the practice of good medicine. Therefore, the student should learn how to prepare one, even though in many instances he may be required to accede to third-party demands. The importance of a complete, unaltered medical record is often emphasized as a defense against malpractice claims. It must be remembered, however, that evidence works both ways. Anything you write in the record can also be used against you—or against your patient, as for denying coverage, foreclosing employment opportunities, or indicting for a crime.
What is not written in the chart could also be grounds for criminal prosecution (vide infra).
If you need to make an addition or correction in the record, mark through an error with a single line and initial and date any change. The worst thing you can do if served with a lawsuit or notice of an audit or investigation is to try to “fix” the record.
Scrupulous honesty is, and always has been, a mark of a good physician or scientist. Combining this quality with discretion in recording is of increasing importance. This is especially true whenever records are converted into computerized format. Once data are in a networked computer, limiting dissemination or correcting errors may be virtually impossible.
Record-keeping offenses, including illegible handwriting, are increasingly being used as a pretext for disciplinary sanctions, including delicensure.
The Health Insurance Portability and Accountability Act of 1996 and Other Laws
Health Insurance Portability and Accountability Act of 1996 (HIPAA) has had a profound effect on the medical record. First, it turned any misstatement to any insurer into a federal crime. This includes errors in coding procedures such as not specifying the various levels of complexity of office visits. Charts may be seized by federal agencies in order to investigate physicians and facilities for billing improprieties. The notes for each visit are expected to include information to justify the procedure code.
Second, the HIPAA Privacy Rule created a large number of procedural requirements that “covered entities” are obliged to follow. A “covered entity” is a “provider” that files electronic claims or engages in certain other electronic transactions, largely related to payment. Patients now have the right to demand copies of most records, with some narrow exceptions such as psychotherapy notes, and to ask for revisions. The usual precautions about altering the record apply. Although access to records by caregivers may be impeded, a very large number of private and governmental entities have expanded access to information in the records. The student and “covered” physician will need to be aware of the procedures that apply to them. The prerevolutionary physician will want to learn about the “country doctor exception” for noncovered entities (U.S. Department of Justice, 2001).
Third, the transaction code sets rule of the HIPAA requires submission of insurance claims in a standard format. This may require
collection of data that have not been part of the traditional medical record (such as the patient’s shoe size in a podiatrist’s records). The ultimate objective of influential agencies and organizations is a fully electronic medical record, with its inevitable constraints on what must be, can be, or cannot be recorded. The effect of translating the medical record into numeric codes and back again will have interesting results, perhaps comparable to the translation of a poem from English into Chinese and back again.
collection of data that have not been part of the traditional medical record (such as the patient’s shoe size in a podiatrist’s records). The ultimate objective of influential agencies and organizations is a fully electronic medical record, with its inevitable constraints on what must be, can be, or cannot be recorded. The effect of translating the medical record into numeric codes and back again will have interesting results, perhaps comparable to the translation of a poem from English into Chinese and back again.
Physicians will face some difficult ethical dilemmas, most clearly illustrated in 2004 by federal prosecutions of physicians related to the prescribing of controlled substances, especially opioid analgesics. At least two states have a “doctor shopping” law. The Florida statute,1 brought to attention because of drug allegations against prominent radio talk-show host Rush Limbaugh (Schlafly and Gregoire, 2004), makes it a crime for a patient not to inform a physician of visits to other physicians in the previous 30 days if controlled substances were prescribed. Physicians who do not make adequate efforts to obtain information of this type could also face criminal conviction or delicensure.
Patient admissions of behavior such as using someone else’s prescriptions create liabilities for both patient and physician. An Arizona physician (U.S. v Jeri Hassman, M.D.) pleaded guilty to four felony counts of being an accessory after the fact to patients’ illegal possession. The facts were documented in her records, yet she had not breached patient confidentiality by calling the police to report the patients for having used medications prescribed for someone else. Although this author knows of no patients who have been indicted for such behavior, the admissions can be used to pressure patients into testifying against physicians.
Other items that might have legal repercussions include patients’ discussions about the use of illegal substances by themselves or by family members; information about the possession of firearms in the event that this is or at some point becomes illegal; patients’ (or their parents’) refusal to comply with certain state mandates, for example, immunizations; and certain child-rearing or religious practices. This author is deliberately not including samples of patient questionnaires that contain such items as part of the social history, despite the recommendations of various professional societies. Patients who are concerned about misuse of the information—by hackers, blackmailers, hostile ex-spouses engaged in custody battles, or government agents—may refuse to answer these questions or may even change physicians. More likely, they will simply fail to answer honestly.
Pedagogy
When first seeing patients, it is hard to remember all the parts of the history and all the questions in the review of systems. Therefore, a well-tested outline is given here (although the student may wish to substitute a different one supplied by his school). After examining about 100 patients using this form, the student will know it by heart. At that time, it may be substituted with a shorter form.
The educational principle is that initially one is well advised to be complete (even if it means being labeled “OC” or obsessive-compulsive) and only later to use truncated approaches. This general principle of medicine applies to far more than just the case history. First of all, if one can perform, say a complete neurologic examination according to the outline, then at any future date, one can revert to this examination when confronted with a patient who has a neurologic problem and not be limited by the currently ubiquitous “grossly normal.” Second, if one rigorously follows this outline, one incidentally gains a great deal of experience with the normal, enabling one to recognize variations of the normal and to pick up subtle abnormalities. Third, the use of this outline in conjunction with a differential diagnosis will quickly convince even the neophyte of the power of a thorough examination. Finally, as the repeated examination becomes faster and faster, the student gains a salubrious sense of mastery that must be experienced, literally, to be appreciated.
You will be richly rewarded for the time spent writing and rewriting your history, not only in your case presentations but also in the development of your skills in acquiring the information and formulating diagnostic hypotheses.
How Much Time Does the Examination Take?
When I was a junior medical student, it took 2 hours for me to obtain a complete history. A complete physical examination took another 2 hours. To record this information, to construct my differential diagnosis, and then to add the laboratory tests that we were supposed to do ourselves (routine and microscopic urinalysis, hemoglobin and hematocrit, white count and differential, and electrocardiogram) took another 2 hours, making a total of 6 hours. I should add that most of these patients had but one major diagnostic problem; nevertheless, this problem was often a diagnostic challenge and required the student to do considerable reading.
After three medicine rotations, we could perform and record a complete history and physical (without laboratory work) in the outpatient department in about 2 hours. At that time, I was once assigned a woman who was deaf and dumb. Because the entire history, questions and answers, had to be written longhand, it took me 4 hours. The 4 hours were well spent because, after visits to many doctors, the patient’s diagnosis was finally made. She suffered from what would now be called neurocirculatory asthenia. Previously, she had received only incorrect diagnoses carrying an ominous prognosis. Her secondary neurosis was completely reversed after I saw her, one of my first solo transference cures.
By the time I was an intern, I could perform and record a good two-page history and physical in 1 hour, only occasionally missing nystagmus or failing to elicit muscular fasciculations. At the time of my oral examination in internal medicine, 7 years after graduation, I could do a complete history and physical on two patients in 1 1/2 hours.
The student should not be discouraged by what at first seems an overwhelming task. Attention to detail at the beginning is time consuming but necessary and richly rewarding in the long run. For faculty to say, “we can’t teach this in our curriculum because there is not enough time” is analogous to a surgeon declining to insert an artificial heart valve because it would take more than 2 hours.
Model Outline of Gerry Rodnan, MD
The following is an abridgment and revision of the outline given to our class at the University of Pittsburgh in the fall of 1958 by our course master, Dr Gerry Rodnan.2
I used it with good results for 10 years, after which I became a consultant and was allowed to improvise.
A. Identification
Name, age, sex, marital status, color, occupation, religion, birthplace (state or country), referring physician and/or agency, date of examination (including year).
B. Informant and Reliability
C. Chief Complaint
D. Present Illness
The present illness is not simply a complete but disorganized catalog of statements and facts. The organization of the history is based on two principles:
The major problem from which the patient is suffering must be dissected free of other unrelated information.
The progression of the major disease from its inception must be made clear, culminating in an evaluation of the current effects of the illness on the patient’s life.
E. Past History
General health: Give the patient’s estimate of his health in general. Body weight: present, maximum, minimum, recent change. Any significant facts from previous physical examinations (military, school, insurance, employment, etc.).
Serious illnesses: Record any infectious disease or prolonged illness.
Injuries: Broken bones, lacerations, or other injuries.
Operations: Date, diagnosis, postoperative course, biopsy reports.
Admission to other hospitals: Record chronologically, giving the name of the hospital and physician and the source of the information. List admission and discharge dates; give a brief summary of presenting symptoms and significant physical or laboratory findings if known, diagnoses, and therapy.
Past admissions to this hospital and outpatient department: If the patient has been seen frequently in the outpatient department, each visit does not need to be summarized, but appropriate resumés of time intervals or change in symptoms must be recorded. Such hospital admissions and clinic visits should be summarized chronologically in the following form: Number of admission (first, second, etc.):
Service (medical, ENT, surgical, etc.):
Date of admission:
Date of discharge:
Operations:
Summary: This summary should be sufficiently detailed to contain all pertinent symptoms, physical findings, laboratory results, medications, and course in the hospital.
Current medications
F. Review of Systems
The chief symptoms referable to each system are reviewed. Information that belongs with the present illness will frequently be obtained and should be recorded there. Repetitions are to be avoided by referring to preceding sections that contain the same information.
Skin: Abnormal pigmentation, sweating pattern, bleeding, bruising, eruptions, itching.
Lymph nodes: Enlargement, pain, sinuses, drainage.
Head: Headache, injury, fainting, seizures.
Eyes: Vision, inflammation, pain, diplopia, scotomata, exoph thalmos, glaucoma.
Ears: Hearing, pain, discharge, tinnitus, vertigo.
Nose and throat: Abnormal odors, discharge, bleeding, obstruction, pain, sore throat, change in voice, hoarseness, goiter.
Breasts: Masses, pain, discharge.
Cardiovascular, respiratory: General exercise tolerance, dyspnea, cough, sputum (amount, description), wheezing, hemoptysis, chest pain, fever, night sweats, orthopnea, edema, cyanosis, hypertension, palpitations, history of heart murmur, treatment with cardiovascular drugs (such as digoxin, diuretics, or nitroglycerin), intermittent claudication, leg ulcers.
Gastrointestinal: Appetite, condition of teeth and gums, sore tongue, dysphagia, nausea, vomiting, hematemesis, constipation, diarrhea, unusual stool color or consistency, abdominal pain, jaundice, results of gastrointestinal X-rays, food intolerance, rectal bleeding.
Endocrine: Growth, body configuration, symptoms of increased or decreased metabolism. Polyphagia, polydipsia, polyuria, glycosuria. Sexual development, impotence, sterility, menstrual history (age at onset, cycle, duration, amount, amenorrhea, menorrhagia, metrorrhagia, dysmenorrhea, date of last period, premenstrual edema and tension, number of pregnancies, induced or spontaneous abortions, stillbirths, live births, obstetric complications, age of menopause, hot flashes, postmenopausal bleeding).
Allergic and immunologic: Urticaria; angioneurotic edema; hay fever; asthma; eczema; sensitivity to drugs, foods, pollens, dander. Immunizations and skin tests.
Musculoskeletal: Pain, swelling, stiffness, limitation of motion of joints. Fractures, serious sprains.
Neuropsychiatric: Headache, convulsions, loss of consciousness, paralysis, weakness, atrophy, spasticity, tremor, involuntary movements, gait, incoordination, pain, change in sensation, paresthesias, incontinence, sweating pattern. Predominant mood; anxiety; phobias; sleep pattern; memory; judgment; thought content (delusions, hallucinations); history of psychiatric care, sexual adjustment, attitudes toward friends, associates, family, disease.
G. Family History
Record the age and health (or death and cause of death where appropriate) of parents, siblings, and children. Investigate the familial incidence of obesity, diabetes, cardiovascular and renal disease, cancer, neuropsychiatric disease, allergy, blood dyscrasias, arthritis, glaucoma, and infectious diseases such as tuberculosis. Many diseases are clearly heritable; many others have an important hereditary “tendency.” A careful family history may suggest a good diagnostic possibility or may provide support for a tentative diagnosis.
H. Social History
Record the nativity, occupation, marital adjustment, and especially the patient’s emotional relationship with the parents throughout his life. The patient’s birthplace, residences, and education are important. The marital history includes age, health, occupation, educational level of the marital partner, number of children, and the marital adjustment. Describe the “extended family group.” Also, who lives with the patient at home (not necessarily the same as the “extended family”)? Learn exactly what the patient does in his occupation with particular reference to the degree of emotional tension or health hazard. What provisions are there for disability compensation and other marginal benefits? Are there debts or economic problems that will influence convalescence? How much does the patient participate in the civic, social, religious, and political activities of his particular economic and social group? How do his opinions or practices differ from those of the group (this presupposes previous knowledge or inquiry into the group opinion)? What are the medical opinions of the group? Find out in detail how the patient spends his day, what his hobbies are, how much he relaxes, how much he sleeps, and how much physical activity there is. Learn the patient’s dietary habits; this usually requires specific inquiries regarding each meal. Are tobacco, alcohol, narcotics, or other drugs used? If so, to what extent?
I. Physical Examination
Vital signs: Temperature, pulse, respiration, blood pressure (both arms and one leg, record position), height, weight.
General appearance: Development, nutrition, mental status, apparent age, race, sex, position in bed, comfort, attitude toward examination, degree of illness (acute or chronic), obvious abnormalities. A short statement embodying these features should always introduce the physical examination.
Integument: Skin: color (jaundice, pallor, cyanosis, pigmentation, erythema), temperature, texture, moisture, eruptions, petechia, telangiectasia, nodules, scars. Nails: color, shape, texture, subungal hemorrhages, paronychia. Hair: distribution, texture, quantity, color.
Lymph nodes: Size, consistency, tenderness, mobility, sinuses; description of cervical, occipital, supraclavicular, axillary, epitrochlear, inguinal, and femoral nodes.
Skull: Size, contour, tenderness, bruit.
Eyes: Vision, protuberance; extraocular movements, nystagmus, strabismus; lids, sclerae, conjunctivae, cornea, ocular tension; pupillary size, equality, regularity, reactions to light and accommodation; ophthalmoscopic examination of lens, vitreous, discs, retina (scars, pigmentation, hemorrhages, exudates, macula), vessels.
Ears: Hearing, air and bone conduction; pinnae, external canal; drum, perforation, discharge.
Nose: Mucous membranes, obstruction, polyps, discharge, septum, sinus tenderness and transillumination.
Mouth: Color and lesions of lips; odor of breath; size, position, tremor, papillae, color, coating of tongue; number, condition, and alignment of teeth; pigmentation, ulceration, bleeding, in – fection of gums; eruptions or pigmentation of buccal mucosa.
Throat: Position of uvula; color, exudates, lymphoid tissue in posterior pharynx; tumors or ulceration; tonsils; voice, vocal cords.
Neck: Contour, mobility; tenderness, masses; thyroid size, consistency, bruit; tracheal position or tug; salivary glands.
Breasts: Size, contour, tenderness, masses, discharge, scars, nipples.
Thorax and lungs: Inspection of thoracic contour and respiratory motion with special attention to the detection of diffuse obstructive or restrictive impairment of respiratory mechanics; palpation for tenderness, fremitus, rubs, wheezes; percussion, including descent of diaphragms; auscultation of breath sounds, spoken and whispered voice, adventitious sounds (rales, friction rubs).
Cardiovascular: Heart: inspect apical impulse, other pulsations. Palpate apical impulse, thrills, shocks. Percuss heart size, contour (describe in relation to the midclavicular line). Auscult rhythm, quality, and intensity of heart sounds including third and fourth sounds or gallops if present; murmurs (location, timing, intensity, character, transmission; relationship to position, respiration, or alterations in cardiac rhythm); friction rubs. Check for apical-radial pulse deficit (see Chapter 6). Peripheral vascular system: thickening or tortuosity of peripheral arterial walls; abnormal or absent arterial pulses. Character and equality of carotid, brachial, radial, femoral, popliteal, dorsalis pedis (DP), and posterior tibial (PT) pulses. Arterial bruits. Venous distention, pulsation, tenderness, or inflammation. Abnormal venous pattern over chest and abdomen.
Abdomen: Inspection: contour, abnormal venous structures, peristalsis, scars. Palpation: tenderness (local or rebound), spasm, masses, organs (liver, gallbladder, spleen, kidneys, uterus, bladder), heaviness of flanks, fluid wave, hernias. Percussion: organs, masses, shifting dullness. Auscultation: peristalsis, bruit, succussion splash.
Genitalia: Male: development, scars, discharge, tenderness or masses of epididymides and testes. Female: perineum, labia, vagina, cervix, size and position of uterus and adnexae; examine for masses, tenderness, discharge, ulceration.
Rectal: Hemorrhoids, fissure, fistula, sphincter tone; prostate (size, contour, consistency), seminal vesicles; consistency and appearance of feces.
Musculoskeletal: Spine: contour, motion, tenderness. Muscles: tremor, atrophy, fasciculation. Joints: deformities, crepitation, range of motion, swelling, tenderness, heat, redness. Extremities: clubbing, edema.
Mental status: Behavior: appearance, facial expression, activity. Speech: rate, quality, quantity. Mood: depression, euphoria, resentment, fear, anxiety, lability. Content of thought: obsessions, delusions, ideas of persecution. Sensory deceptions: illusions, hallucinations. Sensorium: orientation (time, place, person), state of consciousness, memory (recent and remote). Intellectual endowment (not synonymous with education). Judgment and insight.
Neurologic: Every complete physical examination should in clude a brief survey of the cranial nerves, motor and sensory systems, and reflexes. If there is any indication from the history or physical examination that the patient has a neurologic defect or if the disease that he is suspected of having is frequently associated with neurologic complications, a detailed neurologic examination according to the following outline should be conducted and recorded:
Cranial Nerves
I. Recognition of odors.
II. Visual acuity and fields, optic discs.
III, IV, VI. Pupillary size and reactions, eyelid droop, extraocular movements, lid lag.
V. Sensations of face and tongue, corneal reflexes, chewing muscles.
VII. Facial muscles; taste of anterior two thirds of the tongue.
VIII. Hearing (bone and air conduction, Weber test), nystagmus.
IX. Sensation of hard and soft palate, gag reflex; taste of posterior one third of tongue.
X. Weakness of soft palate, deviation of uvula, difficulty in phonation, vocal cord paralysis, rapid pulse (bilateral lesion).
XI. Sternocleidomastoid and trapezius functions.
XII. Tongue muscles, protrusion and deviation.
Skilled acts: Aphasia, apraxia, agnosia, astereognosis.
Handedness: Record whether the patient is right- or lefthanded.
Meningeal signs: Stiff neck, Kernig, Brudzinski.
Posture, gait, and abnormal movements: Standing and reclining posture; circumduction, propulsion, ataxia; tremors, tics, athetosis, chorea, localized muscle spasm.
Coordination: Finger to nose, heel to knee, adiadochokinesia, rebound, past-pointing, Romberg.
Motor system: Muscle strength, tone, volume, contractures.
Reflexes: Biceps, triceps, radial, knee (clonus), ankle (clonus), abnormal, cremasteric, plantar response.
Sensation: Pain (superficial and deep), temperature, touch, position, vibration.
Autonomic: Sphincter tone, sweating, vasomotor changes, trophic disturbances.
J. Differential Diagnosis
Comments on Historic Information
Reliability
Early in the case record, the examiner is asked to comment on the reliability of the informant. As discussed in Chapter 2, no patient should ever be described as a “poor historian.” If the interviewer has noticed that the patient has trouble remembering events, if the physician has performed the cognitive portion of the mental status examination, as described in Chapter 2, and if, in fact, the patient is cognitively impaired, then it is fair to conclude that the patient has either mental retardation or an acute or chronic dementia. (Unfortunately, the cognitive portion of the mental status examination is performed by asking questions without touching or inspecting the patient’s body. Therefore, some tyros omit this section of the neurologic examination from their physical examination, believing it to be part of the interview. Whatever the reason, this extremely important part of the physical examination is the part most frequently missing from the record.)
Examples
“Reliability: The patient was a pleasant man who attempted to cooperate but who was disoriented to time (missing the day and month, but not the year).”
“Reliability: The patient is disoriented to time but not to person or place. Most of the history of the present illness (HPI) was obtained from his landlady. History of prior illness comes from our inpatient records, but the outpatient records were not available at the time of admission.”
Informant or Source
In the case of the comatose patient, the informant will be a person other than the patient. The informant’s name and relationship to the patient, as well as the duration and frequency of contact with the patient, should be indicated in the upper right-hand corner of the first page of the case report:
“The informant is the patient’s consort, who has lived with her for 2 years.”
“The informant is the patient’s son, who had not seen the patient for 4 years up until the day of admission.”
“The informant is a policeman who discovered the patient in the hallway.”
At times, the old record may be the only source material for the history. In this instance, the informant statement might read: “Patient brought in by the police, who know nothing about him. The only historic material available is from our old inpatient records.”
The reliability of the old records is not to be taken on faith. It is frequently stated that “if it wasn’t documented, it wasn’t done (in the view of lawyers and peer reviewers).” This is an assumption, not a universal truth. In fact, in a study in which nurse practitioners were observed by a research assistant who coded all activities, historic findings (such as medications, the location of pain, and exacerbating and relieving factors) were written down only one third as often as they were elicited (Orient et al., 1983). Of course, if it was not documented, you have no way of knowing whether it was done.
The inverse of the statement is also not necessarily true: That something was documented does not prove that it was done (or done
carefully and competently). In the same study, the act of percussing the spine was observed to occur in only 35% of the cases in which the “results” of this examination were recorded on the patient’s chart. The comparative reliability of checklists and written notes has not been investigated, to my knowledge. On the basis of introspection, I tends to believe an examiner actually listened to the heart if he writes “no murmur or gallop,” even in abbreviated form, but places little confidence in a checkmark on a checklist. The latter might just mean “didn’t notice it,” rather than “looked for it carefully and didn’t find it.” In other words, the proportion of false negatives is thought to be higher for items recorded on checklists. (This author knows of at least one physician who admits that on a checklist, “WNL” means “we never looked” rather than “within normal limits.”)
carefully and competently). In the same study, the act of percussing the spine was observed to occur in only 35% of the cases in which the “results” of this examination were recorded on the patient’s chart. The comparative reliability of checklists and written notes has not been investigated, to my knowledge. On the basis of introspection, I tends to believe an examiner actually listened to the heart if he writes “no murmur or gallop,” even in abbreviated form, but places little confidence in a checkmark on a checklist. The latter might just mean “didn’t notice it,” rather than “looked for it carefully and didn’t find it.” In other words, the proportion of false negatives is thought to be higher for items recorded on checklists. (This author knows of at least one physician who admits that on a checklist, “WNL” means “we never looked” rather than “within normal limits.”)
General Considerations on Authoring the Medical Record
The Physician’s Responsibility
The author of a medical record creates a legacy that may follow the patient for the rest of his life. The record is a literary work and a tool that is supposed to benefit the patient. Creating a good record is a difficult and time-consuming task. Physicians in primary care specialties can easily spend 10% of their professional life authoring patient records. Case histories are created, not taken. It is important to be complete, accurate, legible, and concise and to organize the story in a logical manner. It is also essential to present the patient as a person worthy of respect.
Dehumanizing or Humanizing the Patient: An Example
A second-year medical student approached a patient with dread as she read the note of the outgoing fourth-year student: “This is a difficult, noncompliant 47-year-old alcoholic who comes to the clinic repeatedly for multiple somatic complaints.” The student set a goal for herself of finding out who the person, Ms Green, really was. She allowed the patient to speak without interruption. She discovered that several preventive interventions were overdue and negotiated a plan. As Ms Green left, she told the student that no one else had ever really listened to her.
After the visit, the student added several new items to the problem list: illiteracy, loneliness, grief, and poverty. She also added a narrative description to help keep future students and physicians from being “poisoned” by the record (Chop, 1997):
Margaret Green is a pleasant 47-year-old woman. She was orphaned as a baby and raised in a series of foster homes. She was physically and mentally abused in many of the homes, until finally, at the age of 13, a woman took her in who loved her, cared for her, and adopted her. As she was hard of hearing, she did poorly in school, finally dropping out at age 16 because she could not keep up and because so many children made fun of her. For the next 20 years, she was employed cleaning buildings, but after she turned 40, her adopted mother suddenly died. Her health deteriorated, and she quit working….
Patient Photographs
Many private physicians take a photograph of the patient to place in the record. Besides serving as a useful patient identifier, it adds a human dimension to the record. On occasion, it may be of later diagnostic value (see Chapter 5).
Abbreviations
Although some schoolmarms have attempted to drive abbreviations out of the medical record, human nature remains unchanged. Some institutions even have standing committees to designate certain abbreviations as acceptable, but their pronouncements are heeded about as well as those of the schoolmarms who preceded them. Unless your preceptor has strong opinions, I would suggest the following: use abbreviations only when the context renders the abbreviation totally unambiguous.
Example of an acceptable abbreviation: “The patient was treated with IV MS in 2-mg doses to a total of 12 mg in the first hour.” Here, MS obviously means morphine sulfate.
Example of an unacceptable abbreviation: “In 1986, he was told that he had a mild case of MS.” In this context, the abbreviation is ambiguous, as it could mean either mitral stenosis or multiple sclerosis.
Chief Complaint
The chief complaint (or chief concern) is discovered in the course of the interview (see above) and is not necessarily the complaint that was written on the emergency room sheet by the nurse. Nor is it necessarily the first problem that the patient mentions. Some discussion may be required to elicit the problem that is really bothering the patient most.
The chief complaint is singular. On very rare occasions, one may wish to list two separate chief complaints. In such situations, one is also obliged to produce two separate histories of present illnesses, one to match each of the chief complaints. An exception to this rule is the presence of two symptoms that invariably accompany each other, such as polyuria and polydipsia or nausea and vomiting.
Examples of two separate chief complaints:
“My arthritis has come back” (1-month duration).
“I have been drinking an awful lot of water and getting up five times a night to pee” (7-month duration).
In the latter example, the examiner had discovered, on review of systems, a second pair of problems that suggested one of the types of diabetes, with no apparent relationship to the patient’s rheumatic complaints. Instead of making two chief complaints, the physician could have made the new, more exciting endocrine problem the chief complaint and placed an asterisk beside the rheumatic problem in the past medical history section. (An asterisk beside an entry in the case record means that the problem will be dealt with in the “impressions” or the summary section or, in the case of the experienced physician, on the order sheet.)
The phrase “rule out” should never be used in a chief complaint, as in “the patient was admitted to rule out myocardial infarction.” First, this type of statement does not give the patient’s own description of his illness. Second, it puts the historian (the physician) in a logical dilemma. If he diagnoses a myocardial infarction, he has succeeded in making a diagnosis by failing at the appointed task of ruling it out. On the other hand, if he succeeds in that task, he has
failed to make a diagnosis. Yet the patient still has chest pain or some other symptom. It is hardly desirable to send the patient home with nothing more than the negative statement, “You didn’t have a heart attack.”
failed to make a diagnosis. Yet the patient still has chest pain or some other symptom. It is hardly desirable to send the patient home with nothing more than the negative statement, “You didn’t have a heart attack.”
Sometimes patients are admitted to the hospital by their physicians, and they do not know why. Sometimes they think they know and are mistaken; this can lead to interpersonal difficulties later in the hospitalization. It is a good idea to ask such patients, “Why do you think Dr Jones sent you to the hospital?” A good follow-up question is, “Did he ever actually say that?”
Even patients who are in the hospital because of a doctor’s request deserve to have a chief complaint, which should be stated in specific terms that indicate the level of certainty. For example: “The patient is admitted at the request of the cardiology service for elective coronary angiography.” Such a statement of high certitude would be based either on a conversation with one of the cardiologists or on a letter brought by the patient. An example of a still useful statement with a lesser degree of specificity and certitude is this: “Her local physician referred her to this institution to have her ‘gland problem’ evaluated by Dr Smith.” If you have not spoken to any of the referring physicians, do not assume that the “patient is here to get her digoxin and Lasix adjusted” on the basis of her flagrant signs of congestive heart failure. In reality, the patient might have high-output heart failure due to masked thyrotoxicosis and actually might have been referred to the endocrinology service for definitive therapy.
The worst type of chief complaint is one that uses contemporary medical jargon without giving either the problem or the level of uncertainty. For instance, one medical resident’s note said, “Patient admitted for a tune-up.” To say that this description would be more appropriate to the care of an automobile than of a human being would be unfair to automobile mechanics, who usually ask the customer what problem he has noticed.
The “Problem-Oriented” Medical Record
In the Weed problem-oriented medical record (POMR), it is usual to have multiple “problems” derived from patient complaints, each of which is supposed to have its own SOAP (subjective, objective, assessment, plan) in the record, titled and indexed to a specific problem, although this requirement is usually honored by omission. I have found only one feature to be helpful (the problem list), and that could be harmful to the patient if sent to a third party by mistake. I did not expect the system to outlast the first edition of this book. Although it has been more persistent than most fads, the POMR will not be discussed in detail here. Weed’s terms have no obvious advantage over the traditional “history,” “physical,” “laboratory,” “impression,” and “plan.” Weed’s use of the terms “subjective” and “objective” can be misleading (see “definitions” in Chapter 1). In fact, they may give the impression that the patient’s observations are necessarily less valuable than the physician’s and that the physician’s are somehow untainted by bias, prejudice, irrationality—or humanity. Because the Weed record may distort or restrict the depiction of reality, some have called for its rejection (Donnelly and Brauner, 1992).
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