nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
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Tuesday, July 20, 2010

Initiative: Make Doctor's Notes Available To The Patient

 
An initiative to provide patients with their doctor's notes, has some benefits and some wrinkles.

The benefit for both the doctor and the patient would be to reinforce and refresh what happened in a clinical visit.  Patients are sometimes overwhelmed, or worried, or in pain, and may not remember all that was assessed or discussed. 

The Wall Street Journal (July 20) describes the project:
"A study currently under way, called the OpenNotes project, is looking at what happens when doctors' notes become available for a patient to read, usually on electronic medical records. In a report on the early stages of the study, published Tuesday in the Annals of Internal Medicine, researchers say that inviting patients to review the records can improve patient understanding of their health and get them to stick to their treatment regimens more closely."
On the other hand, the WSJ says, if you read your doctor's visit notes and saw the annotation "SOB" how would you interpret it?  Clearly, it mean "shortness of breath," right?

Here's an example of a clinical note I might write:

32yo WF w 4y hx PND, SOB, c/o incr bilat L ext edema. No sig PH. Meds:  HCTZ, Dig.  Ex: NAD, HEENT clear, lungs CTA, cor RR w/o M.  2+ pitting L>R.  Pulses 2+ U/L ext. No nodes.  Neuro no M/S deficit.  ROM full.  R/O vascular, CHF, renal, metabolic.  Plan:  Met Panel, CXT, CBC, EKG,  Re-eval when complete.

[Note this is shortened and slanted to make a point.  It's not a real patient, and not what I would do.]

Either I have to write all this out long-hand, which would take about three times as long, get it transcribed, or you're going to have to ask me what the heck I was talking about.

Just because you have access to it, doesn't mean you can benefit from it.  More has to happen.  Fortunately, there are medical record software products that can take this jargon and substitute the long form without input from the doctor.  Doctors just need to proofread it, to make sure the software guessed right.

Otherwise, you may find yourself to be the other kind of SOB.

Doc D
 
 

4 comments:

WarmSocks said...

Actually, I can read most of it. For a patient who's been to an appointment, it should be easy to figure out what the notes mean based on what happened during the exam.

Doc D said...

I'm impressed.

It's not uncommon for me to say to my patients, "Remember last visit when we talked about that?" (of course, I can refer to the notes).They say people can recall only 10% of what they've read (one time through). I suspect remembering everything the doctor said could be at least as challenging. Not surprising that access to the notes could help recall.

Thanks for your feedback.

Doc D said...

One limitation just occurred to me. The notes don't really convey the importance of what's there. We generally put the differential diagnosis in descending order of likelihood, but nothing says here that I didn't think the pulse disparity important but thought the history of failure critical, etc. I can usually reconstruct this from the note by thinking it through again. The patient doesn't have that advantage. Even sharing the notes, both pt and doc would still need to be sure they're on the same wavelength.

WarmSocks said...

Most people probably aren't at the top of their game when they're seeing a doctor, which would make it even harder to remember anything about the appointment. That's why I take notes. It's not to be annoying, but so that I can remember what I'm told.

Sometimes looking at the differential dx list is scary, but it can also be reassuring to look up those conditions and recognize all the things that aren't wrong :)

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