Documentation in Medical Records

I have documented my love of documentation elsewhere. I blog to document my life.

I'm not perfect at it. Nobody ever can be. Because perfect documentation would take more time than the original act of knowing.

Imagine. If you were documenting a visit to a nearby tourist attraction. How would you document it perfectly? You could definitely write about it in much detail. But how much detail is enough detail? Would you be writing about everything that you saw on the way? Would you be writing about your thoughts on what you saw? Would you document the planning process? Would you care about other sensations like smell, warmth, etc?

Recording a video might capture more detail. But a video can't really capture your thoughts unless you speak into it. Even then it can't capture your reflections unless you reflect loud while shooting yourself. But how much can you videograph? Where do you store these videos

Maybe it's possible to categorize and selectively review any moment from the past using a futuristic memory capture program like shown in Black Mirror. But, seriously, who has the time?

Perfect documentation is not equal to complete documentation. Documenting all the tiny details would not be relevant at times. But sometimes the tiniest detail can be very relevant.

This is especially true in medical documentation. Patient's cousin is a diabetic - relevant. Patient had a day old chicken curry in the morning - relevant. Patient was advised to take so and so medication before food two times a day for 5 days and review if his problems didn't subside - relevant. Patient is anxious - relevant. Patient reached hospital at 9 am - relevant. Patient teaches in an anganawadi - relevant.

Documenting all the relevant information is important.

But, when there is too much information, organization of this information in an accessible manner itself becomes important. Because ultimately, the purpose of documentation is to preserve information for the future so that when one looks back in time, it is possible to accurately interpret history (and avoid controversies. Did Swami Vivekananda's speech at the Parliament of World Religions get voice recorded?)

Courtesy: Some CS Professor (Reddit)

I once saw my consultant Orthopaedician write the timeline of a patient's visits to hospital and management in her case sheet. This was not really necessary for him to document because none of the information was new or not available elsewhere. Her discharge summaries and OPD case record had all those details. But what the consultant did by summarizing all that in a single page is make it easier for recalling everything at a single glance. The timeline itself added value to the documentation.

Elsewhere, A Country Doctor writes in his blog:

Family doctors had the patient’s active problems and their medical, surgical, social, family and health maintenance history on the inside left of the chart, along with medications and allergies. Our office notes, filed in reverse order to the right, were to the point and only dealt with the things we had time to talk about that day. But the background information was always in view and on our minds. We even used to scribble little side notes, like the names of pets and grandchildren, hobbies or favorite travel destinations and sports teams. The problem list helped us see our patients as individuals, not just “the chest pain in room 1”.

This was an eye-opener for me. I am used to knowing patients' name by their case record and calling them by their name. But many times than not, I would never know the name of the person accompanying the patient, let alone their children or pets.

Documentation is an art. It can be perfected only when you know the subject deeply. And when it comes to medicine this amounts to spending quality time with the patient and getting to know them rather than just their illness(es). Like artists, make your documentation picturesque. And people will enjoy it.