Note Sharing?

[docB]

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One of the systems in town just sent out a notice to all providers that from now on patients will have easy access, via internet, to all of their notes. They cite a lot of reasons for this such as better understanding of their meds and better compliance. But how will clinicians document things that are clinically important but unflattering to the patients? I frequently document that patients were hostile or demanded that I do something I thought wasn't right. I know patients have always been able to get their notes if they wanted them but there was a process. If every patient we see can just sit home and surf their chart with a "Hit this tab to complain button" on every page I'm going to open the rest of my career writing letters about how "obese" isn't an insult and "noncompliance" and "noncompliance with a really good excuse" are the same thing medically. Honestly this is likely to reduce all notes the useless banality of those "This is a pleasant, radiant, wonderful... thank you for this glorious consult." notes we read from the inpatient guys.
Is anyone here dealing with this already?
TBH this is another step toward wearing body cams. For the record, again, I think Birdstrike is absolutely right on that one.

 

[skougess]

One of the systems in town just sent out a notice to all providers that from now on patients will have easy access, via internet, to all of their notes. They cite a lot of reasons for this such as better understanding of their meds and better compliance. But how will clinicians document things that are clinically important but unflattering to the patients? I frequently document that patients were hostile or demanded that I do something I thought wasn't right. I know patients have always been able to get their notes if they wanted them but there was a process. If every patient we see can just sit home and surf their chart with a "Hit this tab to complain button" on every page I'm going to open the rest of my career writing letters about how "obese" isn't an insult and "noncompliance" and "noncompliance with a really good excuse" are the same thing medically. Honestly this is likely to reduce all notes the useless banality of those "This is a pleasant, radiant, wonderful... thank you for this glorious consult." notes we read from the inpatient guys.
Is anyone here dealing with this already?
TBH this is another step toward wearing body cams. For the record, again, I think Birdstrike is absolutely right on that one.

Honestly very very few patients are reading their notes. This worry is way overblown. Think of your average ED patient. Are they in good command of their general health and health literacy? The patients you’ll have to be most careful with is the “hx of EDS, Fibro, POTS, non-epileptic seizures” that will be reading their notes in real time.

 

[Birdstrike]

One of the systems in town just sent out a notice to all providers that from now on patients will have easy access, via internet, to all of their notes. .... But how will clinicians document things that are clinically important but unflattering to the patients?... If every patient we see can just sit home and surf their chart with a "Hit this tab to complain button" on every page I'm going to open the rest of my career writing letters about how "obese" isn't an insult and "noncompliance" and "noncompliance with a really good excuse" are the same thing medically...

If we truly live in a "patient = customer and customer is always right" world, then we have to acknowledge patients might read our (actually their) medical records. I stopped putting "obese" in patient's exams about 10 years ago for this reason. Who are you helping by writing "obese" in the chart? A future doctor of the patient who's blind, or can't interpret roundness?

Every chart should be written keeping in mind what it would sound like if read later by a lawyer, jury, medical board, DEA agent, your boss, or yes, the patient.

 

[Apollyon]

Think of your average ED patient. Are they in good command of their literacy?

More to the point.

 

[docB]

I understand the points. I do put "obese" in the chart. I have to justify why their risk factors give them a HEART score that indicates admission for a work up and other reasons.
But if you sanitize every chart where do you document stuff that would piss off the patient but is crucially important to dealing with complaints, admin actions and so on. It's completely important and necessary to document when patients are hostile, threatening, threatening to call administration, threatening to file complaints, demanding narcotics or other non indicated treatments, etc. Do you keep some other record of that?

 

[Vandalia]

Patients have had access to their records for decades. Those who are interested in what you wrote will obtain the records anyway, those who aren't, won't.

Thirty years ago I was dealing with irate patients who wondered why the physician called them an "SOB."

"Well, what did you see him for?"
'Well, some chest pain a little shortness of breath ...."
"Hmm. What would the acronym be for "shortness of breath" (this was the military so that was a relevant question)?"
"S.. O... .... oh...."

If you have a patient who is upset that you called her "obese", believe me, she is already upset about something else you did or did not do.

 

[GeneralVeers]

I don't worry about the Borderlines or the Karens. They are free to waste their time writing complaint letters. Nothing I do will ever satisfy these monsters.

 

[NITRAS]

I‘ve had a few question from patients on results that had resulted from when looked when I rounded.

Honestly, the biggest issue issue I had with patients about documentation was a fellow who previously was dying of Likely an infiltrative cardiomyopathy. In his 20’s he suffered an injury while in the military which resulted in an unhealing wound to his leg, for which had been on disability for since. His family figured out that this cardiomyopathy had nothing to do with his injury and his widow would no longer get benefits. His family and he raised a stink about it.

 

[BoardingDoc]

I understand the points. I do put "obese" in the chart. I have to justify why their risk factors give them a HEART score that indicates admission for a work up and other reasons.
But if you sanitize every chart where do you document stuff that would piss off the patient but is crucially important to dealing with complaints, admin actions and so on. It's completely important and necessary to document when patients are hostile, threatening, threatening to call administration, threatening to file complaints, demanding narcotics or other non indicated treatments, etc. Do you keep some other record of that?

I am a big fan of direct quotes for any of these issues. Patient states "Why aren't you treating my F***ing pain? I told you only dilaudid and benadryl works!" Multiple non-narcotic analgesics offered and refused by patient.

I add things like that to my MDM all the time with problem patients.

 

[Birdstrike]

I understand the points. I do put "obese" in the chart. I have to justify why their risk factors give them a HEART score that indicates admission for a work up and other reasons.
But if you sanitize every chart where do you document stuff that would piss off the patient but is crucially important to dealing with complaints, admin actions and so on.

You don't have to sanitize or leave out important facts. Example: Nurse puts in height & weight. EMR spits out a BMI of 30.

With that alone, it's already in the chart that they're obese without you having to write the word. That being said, if you need to write "obese" in the chart, without BMI and/or height/weight doing the talking, then write it. It's not my hill to die on and I don't feel that strongly about it one way or another. Its just more a way of thinking that the chart is not a closed document for my private viewing. Instead, assume it will be read by the patient and others I mentioned above. That's all.

Thinking that way leads to me changing a few things here and there, but not that much.

 

[Apollyon]

Patients have had access to their records for decades. Those who are interested in what you wrote will obtain the records anyway, those who aren't, won't.

Thirty years ago I was dealing with irate patients who wondered why the physician called them an "SOB."

"Well, what did you see him for?"
'Well, some chest pain a little shortness of breath ...."
"Hmm. What would the acronym be for "shortness of breath" (this was the military so that was a relevant question)?"
"S.. O... .... oh...."

If you have a patient who is upset that you called her "obese", believe me, she is already upset about something else you did or did not do.

Remember the COWs? Not the bovine, but, "computer on wheels". But, someone was disaffected that another person called them a cow at work (if the shoe fits...), so, now, it's a WOW - "workstation on wheels".

Or, think back to the guy in DC in the 90s, who said that, due to money, they would have to become "niggardly" with the budget. Nobody used a dictionary, but, dude lost his job.

 

[dadaddadaBATMAN]

I understand the points. I do put "obese" in the chart. I have to justify why their risk factors give them a HEART score that indicates admission for a work up and other reasons.
But if you sanitize every chart where do you document stuff that would piss off the patient but is crucially important to dealing with complaints, admin actions and so on. It's completely important and necessary to document when patients are hostile, threatening, threatening to call administration, threatening to file complaints, demanding narcotics or other non indicated treatments, etc. Do you keep some other record of that?

I still write these things. I just write them in a way that is undeniably true and accurate, and requires some medical fluency to understand.

For obese or morbidly obese I typically just include bmi>30 or 35 in the same spot I’m listing it. It means the same thing to anyone who needs to know.

Pain seeker: “patient requested dilaudid. Offered Tylenol, toradol flexeril, lidocaine patch, which were declined. Asked pt what had worked in past. Pt stated he had some luck with morphine, fentanyl, oxycodone. Discussed these weren’t indicated. Pt subsequently removed their iv and left ed, screaming at nursing staff and disrupting care of other patients, eventually requiring security escort.”

This takes about 10-15s to dictate and is incontrovertible, accurate and gives a complete picture for any future doc.’

Also if you have admin that even remotely humor a complaint in a threatening or hostile patient you need new admin. No tolerance for that bs.

There are also a lot of patients where a one liner can accomplish a full picture. “This patient has a history of pots, eds, functional neurological disorder and chronic Lyme” pretty much paints a full picture for everyone while remaining objective and accurate.

 

[Siggy]

Remember the COWs? Not the bovine, but, "computer on wheels". But, someone was disaffected that another person called them a cow at work (if the shoe fits...), so, now, it's a WOW - "workstation on wheels".

Or, think back to the guy in DC in the 90s, who said that, due to money, they would have to become "niggardly" with the budget. Nobody used a dictionary, but, dude lost his job.

Every hospital has the same story about COWs and no one knows who the story comes from first hand... therefore I still call them COWS.

 

[clibby]

For those who don’t know, this isn’t just a “customer service” thing. This is based on a federal regulation from the 21st Century Cures Act. All notes, including nursing notes, and test results need to be shared with the patient via a portal if your system offers one (which most do due to other incentives).

As long as you are documenting like it will be read in front of a jury, nothing should have to change. If this makes you have to change a lot of the way you document, then that is probably a good thing too.

I personally love that we can do a covid/influenza swab or STI test and tell the patient to check their portal in the morning for a result so we don’t have to do callbacks.

 

[Rekt]

I just use as much medical terminology and abbreviations as possible now.

I write things like obese and drug seeking behavior all the time. I also tell them in the room that the Ed isn't used for getting narcs so they already know anyway.

Who cares. Let them read it.

 

[GeneralVeers]

I just use as much medical terminology and abbreviations as possible now.

I write things like obese and drug seeking behavior all the time. I also tell them in the room that the Ed isn't used for getting narcs so they already know anyway.

Who cares. Let them read it.

Agreed. Let administration document that they are instructing me to give narcotics inappropriately.

 

[southerndoc]

Agreed. Let administration document that they are instructing me to give narcotics inappropriately.

I usually don't put drug-seeking behavior. Sometimes I do, but it's rare. I'm more likely to write something like patient refusing all non-narcotic pain medications, negotiating for narcotics, requesting to change physicians (doctor shopping) after I advised I'm not comfortable prescribing/given narcotics, etc.

I document enough that people can read between the lines, but it doesn't say in the chart "you're a bad person." Nothing good ever comes of calling someone out in a chart like that... except for paying the plaintiff's counsel.

 

[Birdstrike]

I just use as much medical terminology and abbreviations as possible now.

I write things like obese and drug seeking behavior all the time. I also tell them in the room that the Ed isn't used for getting narcs so they already know anyway.

Who cares. Let them read it.

It feels good until you miss something really bad, go back, read the chart, and everywhere you look it says the equivalent of, "I judged this person." It never hurts to stick to just the facts. That's my two cents.

 

[ERDude]

Yeah we've had open notes for over a year now and everyone had the usual concerns....hasn't been an issue.

RE: drug seeking or other terms with negative implications, I also avoid these (but I did before open notes too). I prefer writing things like "I am concerned for opioid misuse and thus didn't Rx opioids (risk>benefit)". I feel like this appropriately frames it in the lens of patient safety and good medicine but still gets the point across.

 

[Birdstrike]

It's surprising how few people actually read their medical records no matter how easy they are to access. My guess is they take one look and it looks like Einstein's chalkboard so they never past page one or two. But they'll notice if that pharmacy bottle shows with "5mg" percs instead of 10mg tho

 

[Franzd'Epinay]

It's surprising how few people actually read their medical records no matter how easy they are to access. My guess is they take one look and it looks like Einstein's chalkboard so they never past page one or two.

I can't say I blame them. If I didn't know to skip all the minute-by-minute nursing notes, I would give up too.

 

[emergentmd]

I am an ER doc. I like to be left out of pt complaints, board complaints, lawsuits. My job sometimes can be exciting/stressful, but I like my personal/family/time off life to be as low stress as possible. When I go to bed at night and the most important thing I need to worry about is if I am working tomorrow, it is a successful day.

Thus, I chart that way. All my patients that gets discharged looks great, great people, well appearing. I have had a few drug seekers complaining to the medical board about me that required me to go to a lawyer wasting a good 2-3 dys of my time writing legal rebuttals.

Screw that. Drug seekers are now great people who happened to clinically not need more pain meds. Looking at all my charts, you prob can't tell one person from the other b/c they all read the same with bland wording. It is not my job to call out drug seekers b/c I get zero support from admin.

 

[Vandalia]

I usually don't put drug-seeking behavior.

I stuck to objective data.

I didn't diagnose. The BMI is the BMI. If they have four current opioid prescriptions from four different physicians and refused ketorolac with a history of renal colic that is what they have.

Obesity is an issue that pops up a lot in the primary care MDM, but in EM it is rarely explicitly relevant. Yeah, the 5-F's are important for cholelithiasis but by the time I get to writing I should have more to go on than that.

 

[thegenius]

If we truly live in a "patient = customer and customer is always right" world, then we have to acknowledge patients might read our (actually their) medical records. I stopped putting "obese" in patient's exams about 10 years ago for this reason. Who are you helping by writing "obese" in the chart? A future doctor of the patient who's blind, or can't interpret roundness?

Every chart should be written keeping in mind what it would sound like if read later by a lawyer, jury, medical board, DEA agent, your boss, or yes, the patient.

I write obese if it's germane to their complaint. Like if they have panniculitis, or they have SOB + OSA, or they are just flat out fat. And i'm talking Man > 300, woman > 250.
I mean it's part of the physical exam.

Frankly we should be telling these patients they are too fat too. And we should be using the word fat and not "overweight". what good is a doctor if people don't hear from us that they are slowly killing themselves by having a BMI of 50

 

[MechEDoc]

Screw that. Drug seekers are now great people who happened to clinically not need more pain meds. Looking at all my charts, you prob can't tell one person from the other b/c they all read the same with bland wording. It is not my job to call out drug seekers b/c I get zero support from admin.

Back when admin was hanging out every ER doc to dry that didn't manage pain as the patient saw fit, I would give a norco or two in the department, an rx for long enough for next day follow up the appropriate specialist (surgeon, PCP, etc) and then discharge / kick the can down the road. No patients score a big payday from me and their complaints had no merit. My life went by peacefully with less admin interaction. 🙂

Thankfully the pendulum has now swung in favor of few narcotic prescriptions.

 

[Matthew9Thirtyfive]

Every hospital has the same story about COWs and no one knows who the story comes from first hand... therefore I still call them COWS.

Some people call them COWs here. Some people say WOWs. It’s like 50/50.