A Country Doctor Writes:

I used to teach photography and dark room techniques. Now that I only use my iPhone for picture taking, I have forfeited many of the tools that used to help me tell a good story within a photograph.

We may only have 15 minutes with each patient. At least in my opinion, that means you always have to make the choice very early in the visit between going narrow and deep or wide and shallow. A sore knee or an annual physical are like a closeup or a panorama. I can take both kinds of pictures with my iPhone.

In primary care it is often necessary to think in terms of including more than our area of interest in our mental picture of our patient. But if we keep everything in sharp focus, we won’t pay enough attention to solve the problem at hand.

So my mental picture of the problem area ends up being like a photograph with everything surrounding the center of the picture a bit blurry. But that’s not what my iPhone pictures or my EMR notes tend to look like.

The way my EMR prods me to document is by default either panoramic or closeup. My system lets me choose whether to import everything or essentially nothing from the patient’s past medical history. And the past medical history reminds me of a bag person, dragging around everything they own in a stolen supermarket shopping cart. It is a hodgepodge of structured and free texted data that seldom gets updated because of our constant time pressures.

The past medical history has historically been abused by other specialty providers using a common EMR. Some of them have chosen to list everything the patient doesn’t have wrong with them, almost like what a primary care provider calls a review of systems, but under the heading originally meant to give providers a snapshot of each patient.

If a patient only has one medical problem and never had any surgeries, why would any reader of their medical record prefer to view one or more full screens or pages of what has NOT happened to this patient, at least not as of some date in the past when that was nailed down as the patient’s medical profile.

The old paper problem list on the inside left of the chart was by necessity brief, because a page can only hold so much information. Computer scrolling changed all that.

In primary care it is usually sufficient to know that a patient has had two myocardial infarctions and one coronary bypass. I don’t really need the details in order to know how to consider this patient’s risk for future cardiac events.

What I end up doing because of the messy bulk of data in the EMR medical history is insert a macro that says the past history was considered in the visit but not included in the note. I then more and more dictate relevant past history in what I call my visit abstract in my aSOAP note.

It may look something like this:

40 year old male has a normal routine physical. His 10 year cardiovascular risk is average but his BMI is approaching 30. Dietary strategies reviewed.

What more do you really need to read next time you look through his chart?

Or it may look like these examples:

60 year old male with hypertension, COPD and anticoagulated atrial fibrillation returns for followup. No treatment changes made but he has noticed a lump in his lower abdomen and altered bowel movements. Labs and CT scan ordered, anticipate diagnostic colonoscopy.

(The rest of the note is more for billing and prior authorization purposes.)

72 year old female with diabetes and heavy atherosclerotic burden presents with two weeks of increased dyspnea and weight gain as well as increased thirst and episodes of blurry vision. In-house HbA1c is 9. Revisited diet, increasing basal insulin and furosemide dose. Recheck 2 weeks.

(The rest of my note serves little purpose under normal circumstances. If anyone wanted to know that there were bibasilar rales or that the EKG was normal or that the last potassium was fine or that the patient had changed her diet against medical advice, it would be there, further down the screen.)

So, I am again making the case that, by necessity, we often need to compensate for the exaggerated comprehensiveness of the charting tools we are made to work with. The aSOAP note can bring the best aspect of the paper chart into the EMR.