In a post from last year I described Mr G, a patient that by the (emr)documentation should have appeared moribund, looking close to death.  But the person I encountered was awake and alert and reading the Sunday paper.  Very few of the medical notes offered words to describe him.  They were mainly a discussion of systems and problems, and if nothing much had changed, the note opened with word ‘unchanged’.

While ‘unchanged’ can be helpful (especially if you know the patient well, and not much has in fact changed), but repeated day after day- or when the provider is just taking over care from someone else, it’s not.  And it does nothing to bring any sense of humanity to the patient in front of you.

A fairly detailed picture can be relayed in just a few words of prose.   Think of it a bit like Haiku-a poetry of few words, that focuses on a brief moment in time, and a sense of sudden illumination or enlightenment.

Ok that’s a bit melodramatic, but you get the point.

For the patient from the previous post, Mr Y, his initial hospitalist routinely provided a snapshot of Mr Y in his daily note.  For example:    “pleasant, confused as per usual”, or on another day “more agitated than previously, but settles down when family arrives”.  These short opening sentences set the stage for the data that followed and was really helpful.

But all too often words like unchanged, stable get bandied about.  But they don’t really help.  And in Mr Y’s case, weren’t entirely correct.

So it’s important to add a little something to the emr notes, to provide an overall depiction of the human being who happens to be the patient right in front of you.

It just takes a few simple words.