Last weekend I sat down to look at some of the journals I receive at home in the mail. A couple of articles caught my interest, all touching on how we use the medical record.
Dr. Aldebra Schroll describes in an article in Medical Economics how her meticulous medical records were used to deny her patients new insurance coverage after some of her patients lost their jobs and their health insurance. One new patient didn’t tell Dr. Schroll for a whole year that she had Multiple Sclerosis for fear that she would lose her insurance because of her illness.
Dr. Ranjana Srivastava, in her article, Complicated Lives – Taking the Social History in the New England Journal of Medicine tells of when she sat down with a clinic patient in her oncology department. Several doctors rotating through the clinic had seen this woman, but Dr. Srivastava had never seen her before. The woman becomes increasingly upset as the visit goes on. Frantically, the doctor searches through the electronic medical record for a clue. Finally, the patient blurts out:
“Didn’t they tell you? My husband, he died from cancer last week. He died in that hospice of yours.”
The nurse, it turns out, knew what had happened. The doctor asks how.
“Because I talk to her”, the nurse answers.
Also in the New England Journal of Medicine, Dr. John J. Frey III writes about the days when there was no such thing as a “routine HIV test”. I remember in my clinic, we called it a “Special Draw”. Patients usually paid in cash and no claim was submitted to their insurance. We usually stored the results in a special “XYZ” record to protect each such patient’s privacy.
The Journal of the American Medical Association has a commentary about a new Florida law that makes it illegal for physicians to note in a patient’s medical record whether there is a firearm in their household. This standard part of health risk screening in the U.S. is now punishable with a $10,000 fine and disciplinary action by the Florida Board of Medicine.
Why do we write things in our patients’ medical records? It used to be that doctors wrote brief notes to document their treatment. I remember two pediatricians I rotated with during my residency. They knew each other’s styles and preferences inside out. Their office notes might read:
“LOM. Amox”
(Left otitis media, amoxicillin). For a busy pediatrician, an ear infection usually requires no further introduction or explanation. They occasionally scribbled something about their patients’ social histories in the margin or on a problem list that later jogged their own memory, but would be meaningless to other readers.
The world has changed a lot since then, but only the uninitiated expect medical records to be complete and accurate. Patients, doctors, administrators, government, malpractice lawyers and insurance companies all have different expectations from the medical record. Whether we have records scribbled on 4×6 inch cards, typed notes or electronic medical records, their purpose is in the eye of the beholder.
Ironically, I see more and more often that slick, boiler-plate, pre-populated electronic record notes brimming with data that appear to support high-level professional Evaluation and Management coding still have a brief free-text note by the recording physician, explaining in three sentences or less what really happened in the visit. Those brief notes harken back to the brevity of old, but since today’s records are viewed by many more eyes than those of the past, not even those notes always reveal the true essence of the patient-physician encounter.
A Country Doctor Writes: 
Your points are well taken so the question now becomes how to address them because the next generation of physicians are so acquainted with technology that to have written notes will seem antiquated. Most of the docs-in-training around me take their notes digitally on ipads or laptops. And almost all prefer digital copies rather than hard copies of notes.
Computer, transcription or quill, the issues facing us are defining the purpose of the record and meeting the challenge of turning human life events and emotions into structured data, simple enough for statisticians yet individualized enough to let us still use the medical record to document and further the care of the whole patient, not just the measurable parts.