Duly noted.
Doctors these days are plagued with the burden of documenting more than ever. Each chart note must explain in graphic detail what was discussed, how much time was spent face-to-face, and exactly what mitigating strategies will be implemented for any high-risk behaviors or conditions. After 22 years with diabetes, I’ve racked up quite the file. Recently, my doctor’s office has started employing medical scribes to help with the documentation burden.
A medical scribe involves a third person rolling a little stand-up desk into the exam room with you and the doctor and typing literally everything that is said during your appointment, and then summarizing for your chart notes. It’s kind of like a court reporter in scrubs. With the implementation of this service, I’ve noticed some interesting changes in my chart notes. Mainly that there are details in there that I don’t recall being central tenets to our discussion, but somehow make it onto the final chart note. And oh, how I hope I am never judged as a person on my chart notes alone. Because if I was, then I would pretty much be a tired, overweight crankpot who doesn’t work out and eats beans before bed….presumabley to make my husband’s life as uncomfortable as possible?
Ladies and gentelmen, I present to you: Chart Note Highlights From My Latest Endo Appointment. Enjoy. I sure did.
- Alexis states that she is fatigued this week and has been making “horrible food choices”. (For the record, I never used the word “horrible.” I said “poorer,” which to be fair, from a distance, sounds like “horrible.” But come on!)
- Alexis has been eating a low CHO diet and is interested in eating more CHO if it will help with low BG. (Um, I’m always interested in eating more carbs…but they break my blood sugar. You might be misunderstanding the use of the word “interstested” here).
- EXERCISE: elliptical. 3/9/15 visit: notes reduced activity level (I have exercised since that ONE elliptical session I did way back on March 9th. In fact I’ve exercised most days since then. But that’s fine. Let’s just make sure we document that ONE time I did the elliptical. It’s apparently note-worthy but today’s 2 mile run was not. Got it.).
- Eats beans before bed (I actually have no rational explanation of where this note came from. I am not that mean to my husband).
- Constitutional: She appears well-developed and well-nourished. No distress. (Just because I’m well nourished doens’t mean I’m NOT DISTRESSED. Have we talked about the fact that I can’t have any wine and only one cup of coffee a day? I’M TOTALLY DISTRESSED PEOPLE!)
- Body mass index is 28.68 kg/(m^2). Follow-up BMI Management Plan: 4/17/15: pt is pregnant. (Thank you for putting the “pregant” note in there. Because the last thing I wanted to hear was “needs to go one diet.” I’ll be doing that in about 5 more months, thank you!)
Let us all hope we are never defined by our chart notes alone!
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Comments
The day this starts over here, the world is coming to an end. Because I will then start censoring my amusing anecdotes which keep my endo and me entertained. And will start talking about serious business only (I’m German - I can totally do this).
And that would be a very sad day indeed.
If the purpose of the medical scribe is to free up the doctor to talk with you and provide a more accurate record of those discussions, it doesn’t seem to be working as intended. Either that, or it’s intended to protect the doctor/hospital if you sue them - so they can paint you as sedentary patient who eats too many beans and generally makes poorer (or horrible) food choices. My endo does the typing at my appointments; it makes me curious what my chart says.
It sounds to me like the scribe needs to sit closer or at least turn on their hearing aid! Using that scribe would be the recipe for an hilarious game of telephone!