Deep chart reviews

To save time and help guide our conversations when talking with patients, especially when doing consults, we will often look at old charts online and use previous consult notes.

The idea with doing this is that we will review our findings with our patients and/or their families to ensure that things are up to date. At 3 in the morning though, we sometimes get a bit lazy about making sure that everything we have written in the patient's past medical history is up to date and relevant.

We try to do the right thing by gathering information from multiple sources. We know what we need to be doing to be a good health care providers. I've been lazy and not checked info with patients, I know I'm not the only one. This makes me feel guilty and it should.

Mistakes get propagated when this happens. One patient I admitted had a mistake propagated through 3 years of consults. This patient had "bipolar disorder" in their past medical history, but did not have any psychiatric meds. I dug deeper in the chart and in the consult notes 4 years back I saw that the patient had been given a bipolar hip prosthetic. This is a fake hip with two sides to it, the cup and the ball. It is definitely not someone with an illness that should be treated with lithium or another mood stabilizer. Patients with psychiatric illnesses are treated differently than the general population. It's not something health care providers should be proud of. This was emphasized when my team realized the patient they had been explaining away cardiac symptoms as being caused by bipolar illness rather than following it up.

Another I've seen which has more dire consequences is pulmonary hypertension being changed to simple hypertension. The patient had low to normal blood pressure so the temptation to take him off his anti-hypertensives was strong. Doing this would have increased the pressure to the patient's lungs causing damage to the lung tissue.

Old notes can give us insight into a patient with chronic illness and how they first presented. Understanding our patients' health requires us to do more than skim past consult notes. We need to question those notes and make sure they are accurate. Since there are so many of us contributing to a patient's chart, we need to make sure that we use it as a communication tool. We are telling the next person who reviews the chart what the condition of our patient was at this point, and what we know their past medical history to be.

We also need to remember that these are legal documents and it's up to us to document only things we know to be true. If the history is impossible to obtain from the patient, which unfortunately often happens, we need to acknowledge that the history comes from old charts rather than from the patient.

At 3 in the morning when consults are pouring in it can be hard to remember to be diligent in out charting but our patients' health depends on it.


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