The Handbook of Medical Charting

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Dictating Your Charts: A Crash Course

Dictating your charts can be an effective way to write your charts if you know what you are doing. If you do not know what you are doing, your charts are likely to be disorganized, rambling masses of words that your readers cannot make sense of. Depending on what your charting system allows, you may have the option to dictate all or part of your chart. A few key concepts will hold true regardless of whether you dictate all or part of your chart: Dictate purposefully Spoken language is different than written language Keep your goal in mind Stay organized Use a few written notes Proofread Some of these concepts are related and some build on each other. Dictate Purposefully Becoming proficient at dictating can only come with practice. Just reading this article or a similar one will not make you good at dictating. You must practice dictating to become good at it. However, dictating a lot without keeping certain guidepost principles in mi...

Females Shouldn't Have Male Genital Discharge - A Lesson on Macros in Charting

Years ago, I had a bright, efficient resident who was very adept at using macros in his charts. His charting looked complete and detailed at first glance. I had made it a habit to skim through each section of each resident’s note to make sure the gist of the patient’s story was complete to the best of our understanding. I thought I would not have to worry about this resident. Then while skimming a chart I saw this for a female patient: “ penile discharge – negative ” I went to him and talked to him about it. He’d been using the same macro on all his patients and then customizing them. I told him he should be more careful. We had a talk about having his chart internally consistent and why internal consistency made his chart more credible… and how a more credible chart means a more credible doctor. ******* Imagine if you had a chart with an assault victim, you mentioned bruising in the HPI and you forgot to adjust your macro ROS and it still said “no bruising”. The ...

Writing to Show Your Thought Process

Your writing is the window in to your mind. Through your writing, you can show others your carefully curated thoughts and selected experiences. Sounds fluffy and high-minded? It’s actually straightforward to put into practice. Let’s take these hypothetical examples of the same patient encounter: Example 1: A 25 year old male presents with feeling generally unwell for a few days. Says he isn’t eating well. Unsure of whether or not he had a fever. No urinary symptoms. Nausea with vomiting. Feels bloated. Complains also of abdominal pain. Feels like his abdomen is bloated. Feels worse on walking. Example 2: A 25 year old male presents in for diffuse abdominal pain, nausea, vomiting, and distention. 3 days of symptoms. Walking worsens symptoms. Additionally feels generally unwell, and has decreased appetite. No history of similar symptoms. The first paragraph may very well be how the patient described his symptoms at the bedside. The second version shows that...

Tips for Dictating Your Chart

Recently, someone asked me for pointers to improve dictation. I realized that dictation was probably a less common now that in years past, and many new graduates had little or no experience with this skill. I made a list of pointers based on research I’d done for my book, my previous blog post regarding written vs spoken English, my own experience dictating charts, and years of watching my mother dictate the charts she used to bring home from the office. I’ve summarized these points into this brief blog post. The underlying concept to keep in mind as you dictate is that written English is not spoken English . You should not dictate your chart in the way you would speak. If you write the way you speak, your chart will typically be a lot less clear and a lot longer than if you wrote it. Remember that you want your reader to understand your story quickly and easily. A long, rambling, unfocused chart does no one any good . Well-thought out dictation can be just as g...

Written vs Spoken English

Should I write the same way I speak? No. Written and spoken English are different dialects of the English language . Yes, both are still English, but what works well for one is not necessarily work well for the other. This applies to writing in general, and also applies to writing a medical chart. Some examples of the differences between spoken and written English are in the lists below. Spoken Written Tone No equivalent Timing Uses punctuation instead Rhythm Uses punctuation instead Inflection No equivalent Volume No equivalent Imagine reading a move script in your mind vs hearing it read out loud by good actors. It’s a world of difference. Spoken language is rich with other cues beyond the words themselves. Good writing is not necessarily good speaking and vice versa. Good writing is typically more brief, terse, and direct. When reading good w...

Pay Attention to Your Format AKA Use Paragraphs

As chart writers, we often overlook a medical chart’s formatting. What I mean by formatting is simply how your chart looks, how the words are laid out on the screen in front of you. How a chart looks affects how easily and quickly someone else can read it. We do not have control over what some parts of our chart will look like. For example, many medical record systems lock us into a particular format for the review of systems and physical exam. The medical record software often controls aspects of the HPI and medical decision making sections as well. However, most electronic medical record systems allow clinicians some control over the free text sections of the HPI and medical decision making. These parts of the chart contain much of the critical, clinical information. I’ll show you how small adjustments to our prose in these sections can make a big difference in our readers’ ability to quickly understand what we are trying to tell them. I’m going to demon...

Omit Needless Words AKA A Longer Chart is Not Necessarily a Better Chart

A common trap you can fall into is mistaking a longer chart for a better chart. Many people fall into the trap of adding more and more details. Perhaps they think they must show the patient’s complete story, or that they have to draw out every aspect of the story to make the story clear, or that spelling out all the details will defend them better medico-legally. They are all wrong . Classic teaching for good writing is to omit needless words. You should write enough detail to communicate the pertinent part of your patient’s story, no more, no less. You should add needed details. Leave out the needless ones, ones that get in the way. At a certain point, your story gets lost in these other details. Adding those useless details starts to make your communication worse. Writing in copious detail, by itself, is not better writing. Other fields have a saying, “More is not better, better is better.” Through your chart you are communicating with another professi...

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