The Art of the Chart: Documenting the Timeline

The timeline of a patient’s symptoms is often crucial in making a correct diagnosis. Similarly, the timeline of our own clinical decisions is necessary to document and review when following a patient through their treatment.

In the old paper charts, particularly when they were handwritten, office notes, phone calls, refills and many other things were displayed in the order they happened (usually reverse chronological order). This made following the treatment of a case effortless, for example:

3/1 OFFICE VISIT: ?UTI (where ciprofloxacin was prescribed and culture sent off)

3/3 Clinical note that the culture came back, bacteria resistant and treatment changed to sulfonamide.

3/5 Phone call: Patient developed a rash, quick handwritten addition on left side of chart folder, sulfa allergy. New prescription for nitrofurantoin.

3/8 Phone call: Now has yeast infection, prescribed fluconazole.

Each of these notes took virtually no time to create and you could see them all in one glance.

In one of the EMRs I work with (hi, Greenway, it’s me again), when the culture comes back and I need to change the antibiotic, I open the patient’s chart, go to the medication section and hit the + sign. The system then asks me which existing “encounter” I want to use for my new prescription. Excuse me, I am sending in a new prescription right now, doesn’t the system know what day it is? How could I today send in a new prescription dated yesterday?? So I have to create a new encounter, choosing “medication encounter” as the type and then I’m good to go. Sort of. That type of encounter doesn’t display when I later look at my office notes, because it isn’t classified as an office note.

When the patient later calls to report the rash, that telephone call comes to me as a “task” (oh, how I despise that demeaning word…), which will also not enter the timeline of office notes. I can create a medication encounter when I change the antibiotic again, just like with the first medication change. I can then use the same encounter to document the allergy. But if I want my actions to display in any kind of timeline, I have to use the encounter type “chart update”, which will enter the encounter list.

This is all very fussy and, frankly, reminds me of working with the earliest versions of DOS, which many of my readers are too young to even have encountered.

The time it takes to document the simple clinical scenario I described above in my current EMR – and to review the next time I see my patient – compared to when we did it on paper is 5-10 times longer.

Some progress, huh.

I wish the EMR would know that when I add a medication, I am doing it today and not yesterday.

I wish that it would know that it is a medication encounter when I am adding a medication.

I wish the EMR would display the story as simply as the old paper chart. I’m sure it’s possible. Computers can do amazing things. But of course, it’s a question of whom the holy grail actually serves.

3 Responses to “The Art of the Chart: Documenting the Timeline”

  1. 1 lathomasmd March 19, 2021 at 11:17 am

    Why do doctors just bend over and take this? Why aren’t we rebelling?

  2. 2 Melody A March 21, 2021 at 4:40 pm

    I have to ask the same question as the comment above. My daughter in Law teaches and works as a Coder of the EMR system.

    IT is nuts how it is set up. So many inane questions and mostly not to help the patient or the doctor but to protect from liability.

    I feel sorry for doctors because so many decisions that should be in their hands is in others. having to deal with the Insurance industry and Hospital and group administrators that are really only interested in the bottom line. Money.

    I enjoy reading your blog and understanding your point of view about issues.

    Take care and BE SAFE Happy Spring from Iowa

  3. 3 Melissa January 27, 2022 at 10:05 am

    You clearly were the courteous coworker that kept the timeline. In my experience the lazy doctor wrote the follow up right on the lab since it was paper clipped on the front of the chart, which was then filed in the BACK of the chart. Then, the rash call would be on a small pink piece of paper which was likely NOT attached to the chart because it chart was “missing” (read: being filed since the last step in the timeline). Eventually the pink paper may or may not be taped into the timeline, but usually in the “calls” tab. .

    I must say I also don’t miss writing several sentences for two Rxs for an uncomplicated UTI, signing, then looking for the elusive staff person on a Friday afternoon to call or fax, and let the patient know so they aren’t cursing me all weekend because no one told them their Rx was ready. (I do resent my phone won’t accept “Rx”without a fight right now).😡

    My EMR does know what day it is, and writing those prescription is a few keystrokes… no wait, I tell dragon to order those for me. I, too, am a firm believer in the importance of the timeline, but unfortunately my memory is not as nostalgic. Heaven forbid you need an older volume of the chart, or you forget to read that chart cover and write for sulfa again.

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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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