Wednesday, November 16, 2011

What you need to know and why you need to know it

Medical records used to be a helpful tool to communicate to others what was going on with a patient and how to help pass on their care. The same was true when we signed patients out to each other. A mantra that we used was to be sure we told each other what they needed to know about each patient and just as importantly why they needed to know it. What was different about that patient was immediately passed on. Ms. So and so had a colostomy after a perfed tic, she is stable but she has been on steroids! Nuff said, you knew what to watch for and where to go when things went bad. Her medical records had the pertinent positives and pertinent history. You could pick up the chart, know what was going on and get down to business. Now it is just the opposite. We will have a patient sent in from somewhere. With them will be their records. A multitude of pages that list negatives like "No family history of travel outside of North America. Page after page. You have to sit there and play "Where's Waldo" to catch a glimpse of what is going on with them and pray you find the needle in the haystack. Of course it is all computer generated so you know that someone just clicked on a template so all that is written is BS anyway to comply with some CMS thing and to have "it documented in case of litigation". Its bad enough that it was happening in the paperwork but now it is creeping into direct communication about patients. One of the residents was seeing a patient in the ED and called me to run the case. They started with all the things the patient didn't have. I cut them off and said, "What do I need to know, and why do I need to know it?" There was a pause, then more of the BS about fibro and pain scales. I finally said, "Do they need to go to the OR?" A feeble, yes was the reply. Then I asked "why do they need to go to the OR?". Severe abdominal and back pain with free air and dependent fluid on scan was the answer. "Ok, then. What else is important that I need to know?". Crit is 30, they are probably septic and have afib with a recent stent and an EF of 30%. Crisp, clear, concise. Time for a Bard-Parker Scan!


SeaSpray said...

And with time of the essence for some patients ..not to mention physician time.

I wonder if this scenario about referred patients has anything to do with my frustrating pcp to specialist experience?

I always thought when docs sent med recs to specialist there would be a letter with all pertinent info the specialist can use to aid in his evaluation of the patient.

That it was the medical to medical office responsibility to see that they have all necessary info?

That was not the case for me. But what perplexed me greatly was that I was specific about dates and tests the specialist should have. Instead I was told they didn't have one. I read it myself and KNOW it was in recs I turned over to them. I also was SPECIFIC about current labs to be sent and I just had a feeling and so I called the specialist office the day of my appt, receptionist said and they only received labs from former pcp dating back to 2009. GRRR ...I was Exasperated with a capital "E" and more to story, but writing in a post.

None of this was emergent as far as I knew ...although never talked with anyone regarding WHY I was being referred to a specialist.

I was so upset about the potentially bad news I was going to hear and I just wanted the doc to have all the information to put the picture together and I was hoping to have answers ASAP and so was stressing at the potential for delay if he had to wait ...and if I had to go another day. Fortunately was a FALSE alarm ...but I didn't know that when I was worried about the doc having all the info. I am a relatively new patient to the pcp office and maybe that is why.

But even with the scenario you describe hard is it for an m/a to pull a test when they have been given the type of test and date and doctor? That she would actually send labs from 2 and 1/2 years ago and while I was under another doctor? Aren't people supposed to double check their work? And I know mistakes happen, but she also did not provide two other things requested on another day.

Your post gives some light at the end of the tunnel in that you are apparently adept at finding Waldo and so other physicians must have to adapt as this inundation of superfluous info exacerbates in the ever evolving medical world. Maybe the specialist I saw would not have needed the other stuff and only the report for evaluation.

But I didn't know if that was the case and his staff also told me he would want it.

I had to look up "Bard-Parker Scan" - Clever. :)

Andrew_M_Garland said...

What used to be the medical record now seems to be the legal, medical research record, only incidentally useful for treatment.

The lawyers need all of the "patient did not have X" statements to show that the doctors did not miss something important. There must be a "Doctor House" effect in litigation similar to the "CSI effect". Juries may want to believe that a team of 6 diagnosticians spent 4 hours tossing around all of the possible symptoms, diseases, and complications, before they make their large award anyway.

Even so, Dr. House always sticks to the One Disease Rule. He demands that there is only one disease at a time. I suppose that two concurrent diseases makes a clear diagnosis impossible, even for Dr. House.

Medical researchers need the "did not have X" statements to satisfy themselves that the data was properly collected.

No one seems to recognize that generating "template" additions to the record is no more reliable than leaving out medical indications and then inferring later that they weren't there. Yet, you point out, this makes the medical record unreadable by humans.

And, separating the template entries from the useful entries would remind everyone that templates were being used. This would destroy the fantasy that medicine had moved to a higher, computerized state where hundreds of indications are combined to produce the best possible, computerized care.

It might seem that the entire system is being bent toward supporting political claims of greatness, rather than medical effectiveness.