Hello MedHatters!
I’m happy you have stumbled upon this post. If you are thinking about scribing, are in medical school, or are in a medical role where your provider is asking you to dual scribe as well, then hopefully this provides some insight for you.
A medical chart is a legal way to track what the provider did for care of a patient. Additionally, when looking back later, it can refresh the same physician’s memory of what was done or another physician to see what care was provided. A provider can be a physician, a PA (physician assistant), and NP (nurse practitioner), nurse, or other healthcare team member helping with your care that day. You may also see me use the term EMR in this post. This stands for electronic medical record.
If you want to skip all the background and pros/cons of EMR's and charting, then head down to the last header titled "Chart Outline" to see the outline information.
Strap yourselves in; this may be a long post. Edit: this is definitely a long post. Sorry not sorry!
Background
Let’s first do a little background info on this here: EMR’s were in the process of being built/modified since the 1960’s. We had to wait for computer technology to catch up to the public before use, but by 2004 President Bush had a goal for all Americans to have EMR access in 10 years. This garnered support from other government groups-particularly Medicaid/Medicare which serves a very large portion of the United States. By the time Obama came into office he used this to help strengthen our economy in 2009. Around the same time, a law called HITECH was put into place to help garner security of patient information and use of certain electronically devices for EMRs. And by January 31, 2013, all healthcare facilities and to switch to using EMR’s.
In the midst of this, around August 1996 HIPAA was initially enacted. Now, what are all these laws you keep saying are involved? HIPAA stands for health insurance portability and accountability act. It protects the patient/users (called Personally Identifiable Information) from several things including the right to your privacy of information particularly when it came to insurance companies trying to use this information against you. It also addressed the limitations that health insurances used to limit your coverage.
Resources used: Sermo Blog; Healthcare Law Blog; Wikipedia
I know, it doesn’t seem like health insurance nowadays is any more fair, but thank goodness there is some law in place to keep them from going haywire! Now, HIPAA has since been expanded upon. But in every day use, or what I have been exposed to in working in the field before medical school, it is used a lot to make sure we are protecting a patient’s information. This means not sharing information, not going into a chart that we are not part of the healthcare team of, leaving a station with patient information on it up when we aren’t at a computer, and lots and lots of passwords. Oh, and your keystrokes are monitored too. If they have an inkling that you may be doing something illegal (in any capacity, not just going into charts you aren’t supposed to), they, or the hospital, can check. And they most definitely do check.
Now HITECH is basically (again from what I’ve seen) used to not allow personal emails or computers to be using or accessing the hospital EMR. This means that you can only access the EMR on the hospital server, through an approved and security protected computer issued by the hospital itself. This includes desktops, laptops, and workstations on wheels. It also means you cannot use things like Evernote or other note taking apps that are not secure, and you cannot use your personal email to transfer information back and forth. All of it needs to be done with hospital emails, notes on hospital computers (or paper if you really, really need that information for something), and on their servers.
There are some major improvements since January 2013 when the government enacted that all medical facilities had to transfer from paper charts to computerized charts officially. Obviously there was a big pushback as some physicians (particularly the older generation) was not used to using a computer or having to stay on top of their notes. Paper notes also offered a variety of ways of charting. Some physicians had lengthy hand-written notes, others barely wrote down anything.
The paper method also made it more difficult when transferring care or when the patient showed up at a different hospital than where they had been more regularly treated. It also made it more difficult for confluent or continuity of care when patients “hospital shopped”.
“Hospital shopping” is a term usually used in the field as patients who continuously bounce from hospital to hospital or provider to provider to try to get what they want. However medically, may not be the best for them. This is different from someone attempting to find a physician that fits better for them to improve their care or find a physician that aligns more with their own morals or health-goals.
There was also concern when switching to computerized charting about having more access to someone’s healthcare chart. There are many laws in place that aim to prevent and even punish (both legally and with losing someone’s job/career) to keep that from happening. Does it still happen? Yes. Although not nearly as often as people think. Do they basically lose a lot in life when doing so? Double yes.
Hospitals take patient information and confidentiality very seriously. There are courses you must pass during orientation and usually yearly seminars/classes that hospital employees of all tiers must partake in. There are also several additional steps such as passwords, and not being allowed to enter someones chart that you are not actively taking care of, and being cognizant of speaking about patients in areas outside of designated areas to help prevent this.
I understand that to some, having a medical chart is worrisome. I understand your concerns! But know that overall, there is training in place and a consistent push to by all employees to make sure your information is not being accessed without it needing to be.
Pro’s of computerized charting
- Organization & Standardization: Everything is in one area. No worries about if you misplaced a piece of paper. It is all in one online document. Doesn’t matter how many labs, imaging studies, or charts are in that file.
- Streamlining care: It makes patient care more seamless. If you see multiple specialists within the same hospital system, you no longer have to wait for your physician to get a phone call from another physician to catch them up on your care. Your provider can see another provider’s treatment plan and what has been done/hasn’t been done to streamline your care.
- Efficiency/Reduction in order error: As a patient, you tend not to get a repeat test (unless needed) due to your provider knowing if it was obtained. Again, this is helpful when at the same hospital system, but can be helpful at outside hospital systems. This can also help when they need to send you to a specialist. They can see what you have tried/who you have seen already so they don’t send you down the same rabbit hole.
- Time-saving: It’s super easy to transfer your records to another physician. Again, if you are switching your primary care doctor and you are in the same system, you literally don’t have to do anything. If you are switching to a provider in a different hospital system, you fill out a form and they literally fax all of it in one go. That’s it! No paper mound to search for and send!
- It does a better job of tracking what medications you have been given or haven’t been given, and what is ordered and what was done then paper charts. Specifically when in the hospital.
- This has also created new jobs. Namely scribes!
Cons of Computerized charting
As great as medical charting has become, there are some drawbacks or improvements. Most of this now has to do with trying to make more money off insurance companies or insurance companies in general not reimbursing something because you didn’t click what they wanted you to click.
Honestly, there is a whole debate among providers with minimal charting versus charting more to “hit those boxes” so the hospital can be reimbursed for more minute things that you did for the patient. As a scribe my job was to lean one way in this debate. In the future I will have to see which way I sway; if I choose a side at all!
- Insurance companies tend to run the prices and dictate what gets reimbursed and what doesn’t. Providers are being pushed more to chart more for greater reimbursements. This doesn’t mean they are doing more to charge you more, it simply means the provider needs to document every single thing that they did do for full reimbursement. Which can be a pain in the butt (from a scribe’s point of view anyways).
- Increased work: It’s more work to chart the amount that is required now (again, for providers). It may be equivalent to paper charting back in the days, but given that everything is tracked now, healthcare workers are required to fill out several things just on one patient alone.
- Less patient interaction: If you’ve been to the doctors recently (or really any time between 2011/2012 and now), you’ve probably noticed that the physician themselves now has a computer. And they will be typing on it while you two are conversing. This is because the physician is usually looking at a prior note, looking at your medications/history, or typing in orders while having a conversation with you. Why? Well they are trying to take care of everything (including charting) while you two are in the room together. It makes for less one-on-one face conversation. Ultimately, it makes the patient feel not listened to.
- Increased dependency on technology: The downside here is that like in the last bullet point, everyone usually has a computer on them. Whether it is a tech that is getting a blood draw from you, a nurse giving you medications, even down to the registration department. They they don’t have a handheld laptop, they likely have a “COW” or “WOW” (computer on wheels vs workstation on wheels). Or just basically a shorter way of saying a rolling computer + scanner + printer + whatever else they need. Literally no one in a hospital is without a computer.
I’m sure there are more, but seeing as I scribed for 6 years, I’m a little bit more pro-charting as it paid my bills.
What is In a Chart?
There are two main parts of a chart:
- the subjective portion
- the objective portion.
The subjective portion involves what the patient is feeling, explaining, etc. This includes your chief complaint, your HPI, and your ROS. Majority of it is not considered “fact”, but is important in figuring out the story and what may be causing the patient’s issues. The part that is considered “fact” is the patient’s medical history, medications, and allergies. A lot of those can be cross-referenced with other provider’s diagnoses, etc.
The objective portion is the part that the provider adds to the chart. This includes physical exam findings, results, etc. Why is this considered objective? Because your provider goes to school for many years to learn and train to see what your ailments’ underlying cause may be. Their expertise is considered as factual knowledge that they have gained and have applied over the years to take care of patients like you!
Most medical charts are designated as SOAP notes. So we have the subjective portion (S), which is described above. Then we have the objective portion (O), also described above. After that we have the assessment area (A) and lastly the plan (P).
This flow makes the most sense to most people. We first talk about the problem, then go to the physical exam/inspection, then discuss potential diagnoses/label the problem. And finally we discuss how we are going to either take further steps to assess and define the problem and/or what we are going to do to either try to fix or further manage the problem.
Chart Outline
Now, charting is not easy. There is reason pre-med students who become scribes spend many weeks learning the background or charting and then many more shifts/weeks practicing this in real life. Medical students also have to spend time learning how to gather information to chart early on in their education and then have to practice, practice, practice to improve on this skill.
It’s most definitely not an intuitive skill to have and needs work to improve upon. Thankfully though, once you learn this skill, it’s almost like riding a bike! You don’t really need to put a ton of effort into doing it and it always comes back to you.
Part 1: The Chief Complaint (abbreviated CC)
This is the main reason your patient (or the patient you are seeing) is here today for a visit or why sure they in the hospital. You will have many times where a chief complaint is just one concern. But more often than not, you will have patients with many complaints.
If it is just one complaint, great! If not, you can usually pick the top 1-3, and number them. If there are too many complaints, you can always put “multiple complaints”.
If you are truly at a loss for what their chief complaint is, you can always wait until after the HPI is obtained to find out. If you are the one obtaining the history and have absolutely no idea, ask for them to pick one concern that they would most like addressed that day!
Examples of CC’s:
- High blood pressure
- Knee pain
- Nausea, Vomiting, Diarrhea
- Evaluation for hyperthyroidism
- Health Maintenance Exam
Things that are NOT a CC:
- Medication refill. Instead, write the chronic illness or reason for why that person is using the medication.
- Patient here for follow-up. Instead, write what concern they are here for follow-up.
- Re-evaluation. Same concept as above. They may be someone who has been seen in the office before but the staff didn’t obtain why they are coming in. They may be here for re-evaluation of the same problem, or they may be here for an entirely new problem.
- Lab results. Instead, write what they are being evaluated for. i.e. if they are here for TSH results, write concern for hyperthyroidism or some other complaint which led us to that obtaining that lab.
Part 2: The History of Present Illness (abbreviated HPI)
The HPI is the “story” that the patient is telling. Depending on the type of visit will depend on how long this is and how you can arrange it. It also tends to be the hardest part of the chart to learn how to write.
Overall, there are 8 elements of the HPI. I will address what those elements are in a later post detailing the HPI itself. All of those elements help you piece together the story of why someone is there that day and help point you in the direction of what to look for in your physical exam. The HPI in combination with the physical exam helps determine your differential diagnoses.
For emergency medicine, the HPI is usually only 1 paragraph. Since it is an emergent situation (which is why they are in the ER), there is usually one main complaint the provider is focused on. Even if the patient has multiple complaints. Does this vary? Sure. It’s very case dependent though.
It’s also one paragraph because ER physicians like brevity. The patient will usually be in the ER for 8-12 hours or less; so no need to have a gigantic HPI. That’s what time-stamped updates are for later in the chart. The way you organize it is key though; even though it is one paragraph it needs to have good flow.
In outpatient such as in family medicine, there are usually multiple paragraphs. Since these providers tend to see you for your yearly physical exams, you have multiple chronic illnesses you are being followed for, or you wait until you have multiple complaints, the multiple paragraph format suits this area of medicine well.
In general when I use multiple paragraphs, I have each paragraph as a problem. So if we are talking about someones hypertension, then everything grouped with hypertension goes in their paragraph. Say their next complaint is joint pain, then everything about the joint pain goes there. And so on and so forth.
Physical Exam (Abbreviated PE)
Like I said, the HPI is the hardest to learn how to write, because it forces you to develop multiple skills. It also takes the longest to learn when scribing. But the PE also has its own obstacles. With this section of the chart, you are battling learning a whole bunch of new medical terms. You are also battling learning where these medical terms/descriptions go. Because of this, the PE has the most information in it that you need to learn.
The PE is set up by system. Of which there are 12. These systems encompass the body systems that we as humans have that someone has tried to classify in the past. The photo below shows an overview of the 12 systems in an EMR PE (particularly, in the EMR EPIC).
As you can see, there are check boxes and +/- for certain physical exam findings. This page in particular shows the most common things that are clicked/written down for each system. But there are also individual tabs for each system (plus some extra tabs) that goes much more in-depth.
Within an EMR (and PE in general), there are things that should be negative because they are normal. For example, let’s say I’m looking at the eyes section and I put – for discharge in both eyes. This is normal; most people don’t have discharge (or goop as I like to call it) just hanging out around their eyes. But the reason I’m clicking it as negative is because I checked! If I didn’t check for it, I wouldn’t click on it.
Other things get checked off instead of being stated as + or -. Again, if we look under the eyes section, EOM normal and PERRL are check boxes. EOM stands for extra-ocular motion and PERRL stands for pupils equal, round, and reactive to light. Both of these should be normal. Both should always be checked (in this case). Let’s say we checked them and they were both normal; I would click the check box.
And done!
You literally do that for all of the PE. The thing is, as an experienced scribe, you are allowed to see the look at the patient and click off the boxes described in a “no touch” exam. More on that in a later post. But everything else needs to be dictated to you by your provider.
If you are a new scribblet don’t even think about trying to do this yourself. Just wait for the physician or provider to give you the PE. Don’t be a gunner here. You’ll regret it when your provider verbally rips you a new one for putting something down that you shouldn’t have.
And hell, if you happen to be a medical student reading this, you’ll figure it out eventually.
Results
Okay, this section is usually right after the PE. Depending on what EMR you use will depend on how you pull this information in. In general, you want to put the results of the labs or imaging studies you obtained during the patient’s stay here. I’m assuming this is used more in ER and inpatient, as results for specific problems can usually be lumped into the next section for outpatient. But, this part of the chart has a varying degree of how it looks depending on the provider you work for and the type of medicine you are in.
In the EPIC EMR, we had these wonderful things called “dot phrases”. Basically you would add a period and then type in something, and it would automatically pull in a sentence/paragraph you made, vital signs, labs, or whatever it was. You usually had to create these, but some came with the program itself. So for example in the ER, I could type in .newresults or something and it would pull in the newest lab results.
Plan/Medical Decision Making (abbreviated mdm)
This is usually the last part of your actual chart. Again, it is very variable depending on what type of medicine you are in and the provider you work for. It all leads up to if your patient is discharged, admitted, transferred, etc.
For ER, you stick to an MDM. Why? Great question! In the ER this is used to basically summarize from what they complained with/had a concern about when they arrived, to your PE findings, the results, and what your differential diagnoses are. The whole point of this is to rule out something that could kill your patient and to show how you came to your conclusion and what you did to take care of the patient. Another main point of this is so if your patient is being seen again for this issue or is admitted, another provider can quickly review what was done.
If you are admitting a patient for a problem that can kill them (such as a myocardial infarction or heart attack), you need to explain what you did to keep them alive and what you plan on doing to help them as well. Very critical stuff here people. Unless of course you couldn’t save the person. Then you really need to start explaining what you did.
For outpatient we use it as the plan section. MDM doesn’t really fit well here since there is usually more than one paragraph (as there is usually more than one complaint). My favorite way of organizing this to do a combination of the diagnosis and then everything regarding that diagnosis in that paragraph. Similar to an outpatient HPI.
That knee pain you had? I want to put what we discussed and what I want you to do about it. This means I discuss your complaint and my PE findings, and what I suggested you do or what I ordered for you to get done. This would also include all the medications I either want you to try over the counter, what I prescribed, or if I don’t think you need medications for this issue.
And each diagnosis gets their own little blurb about it.
At the end of all of this in the chart you would put when you want the patient to come back. This is either to follow-up on the problem to see if it’s improving or getting worse, to return to discuss any results if you had asked the patient to go get a lab test or imaging test, or just as needed if they don’t really need to be followed up for this complaint.
Patient instructions
Now, this is not technically part of your main note. But this is still necessary. Your patient isn’t going to remember everything you told them. Hell they might not even remember what medications you prescribed. You will likely discuss some of this in your plan, in which case you can copy and paste into the patient instructions.
But this will ultimately print out to be given to the patient. You will want to put what you want them to do and/or to insert information about their diagnosis. Some EMRs also have pre-made information that you can insert in here as well.
There you go! I hope this outline is more in-depth and helps answer any questions you have about the chart itself. Stay tuned for more posts that detail each part specifically. I’ll be working on those posts. As always, let me know what you liked, didn’t like, or what you would like to see next in the comments below!
