“Did You Read My Chart?”

The patient, I surmised, was the one in the wheelchair, with nasal oxygen and an unhealthy red color of her cheeks. The younger woman in the room with her looked like she might be a daughter.

I introduced myself. I had been right about the other woman being her daughter.

It was Saturday clinic, urgent care at our country doctor practice, and the plastic holders with “express check-in” history forms and a scribble sheet for the doctor and the medical assistant were piling up in the pocket of my office door.

“So, what can I do for you today?” I asked.

The woman in the wheelchair gave me a sturdy look and said:

“Did you read my chart?”

My mind raced, thirty years into the past and back again.

As an intern and resident admitting patients to the hospital, I would routinely read up on the patient’s paper chart before entering the room. Each admission took as long as it needed, and the only time pressure I felt was usually my own. The emergency room doctors had already ordered the initial treatments each patient needed.

In practice before computers, I would glance at the problem list and flip through the last few notes, labs and imaging tests while pausing in my office or at the nurses desk, sometimes actually while walking toward the exam room.

Now, with computers that go black after just a few idle minutes, I’d have to log on in order to see any information, and the moments that takes feel like forever. Besides, I can’t very well sit in the last exam room I used and do this, since my nurse needs to room the next patient.

Also, now, with all the checklists we must complete in even the simplest visit, there really is no time during or in between visits to actually sit down and “read the chart”; our time is so pressured and the medical records have become so bloated that we end up just asking the patient, because the pertinent information drowns among the mandated minutia.

“No, there is seldom time to read the chart anymore”, I said.

My patient sighed and gestured to her daughter, who recited her medical history in a monotone voice as if she had done it too many times to count.

The woman had leg cramps, and it was probably because of low magnesium. Her exam was fairly similar to the last note by her own doctor. I did compare my findings and his.

So I prescribed magnesium and two days later we got a call that that had done the trick.

But I don’t think she will ever accept that when she sees a different physician, they will talk to her first, before deciding if it would be worthwhile to steal the time from someone else’s appointment to sit down and read her chart.

3 Responses to ““Did You Read My Chart?””

  1. 1 Lisa February 28, 2017 at 6:08 pm

    My eyes kind of rolled with the question “did you read the chart”. I appreciate your explanation as to why that can’t be done. But as a patient with multiple serious chronic conditions, having a doctor who understands what is going on is important. I keep a one page summary with me that is given to any doctor I see whether I have seen them before or not. It has all the diagnoses and medications, etc. Medical staff used to think that it was odd that I do that, but anymore, they seem appreciative. The bottom line is, if I am really sick, I won’t remember all that information. And my doctor needs to know it.

  2. 2 Anne Shirley March 1, 2017 at 12:30 pm

    My head nodded in agreement with you about the computers.
    I am a sonographer — (I do ultrasound; stenographers take dictation — that’s an explanation I have to do over and over)
    Anyway – I used to get a film bag with all of the patient’s previous images and reports. While the patient settled onto the bed, I could run my finger down the list of previous tests, and still keep half an eye on the patient, and even get a history as I looked.
    Now I am forced to load the patient information system (RIS) and type in the patient MRN and wait for the RIS to find the patient. Our RIS is particularly stupid, in that i cannot get it to organize the exams chronologically, or by test, or by any other reasonable order known to human. It just lists them randomly, in amongst a bunch of other verbiage.
    Or I can go to the image archival system (PACS). That system is more organized, but it only shows me the images, not the previous sonographer’s worksheets, or radiologist reports.
    So what used to take me a minute, now easily takes 4 – 5. Not much time, you say??
    Well, I would rather spend those extra 3 – 4 minutes in scanning my patient, not in scanning the silly computer screen.

  3. 3 drjenniferconroy March 1, 2017 at 1:10 pm

    It is truly not easy to form a good relationship with someone who you’ve just met, and will only talk to for 10-15 minutes. I believe that doctors and patients are BOTH responsible for making the doctor-patient relationship successful. Both parties need to try their best to be accommodating to each other.
    Thank you for sharing this story.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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