Why I type during office visits

A few weeks ago a patient asked me with a hint of irritation in his voice, why I always typed during our visits together. I explained that my notes were more complete and accurate if I do them during the visit.  It was a quick answer to a good question, and although he seemed satisfied, I wished we had had time to discuss it.

My brief answer emphasized the biggest reasons: comprehensiveness and accuracy. My memory is pretty good, but I am human, and my brain is fallible. The longer I wait before I enter information about a patient, the greater the likelihood of omissions and errors, and I believe patients are entitled to complete and accurate documentation of their care. If I ask you, WHILE we are eating in a restaurant, to describe and critique the meal, you will be able to do so with considerable detail. If I ask you several hours later, there will be gaps and errors. If I ask a week later, you will be reporting not on the meal, but on your processed and altered recollection of highlights, probably conflated with other meals and other restaurants. Even for so-called ‘flashbulb’  events like the assassination of JFK or the Challenger disaster, studies have shown considerable inaccuracy in the vivid recollections of responsible observers who are certain about the accuracy of their memories. Eyewitness testimony is the leading cause of false conviction.  I experienced very personably the danger of delayed documentation as a third year medical student when I deferred writing my admission notes on two elderly patients admitted during a busy night until morning, when on morning work rounds I was asked by the attending to demonstrate a new and previously never described medical phenomenon: patellar and achilles reflexes in a patient with bilateral above-the-knee amputations. I conflated the two physical exams.  (The discovery of the Elias sign is described here.)

Lawrence Weed, father of the problem oriented (rather than source oriented) medical record that has become the standard of care, emphasized repeatedly that documentation delayed is fiction rather than fact. (This video is worth every minute you spend on it.)

If I document later, I will get it wrong and leave things out. Guaranteed. 

Diagnosing and understanding illness and its impact on patients depends heavily on stories. Recording the patient’s story (the history) is best done in the patient’s own words. This is only possible if done in real time, which also allows me to validate the accuracy of the story I am recording, by reading back my paraphrasing, often as part of asking a follow up question. “Let me be sure I understand. You are having a severe tingling pain in your left food, and you said you first noted it as an electric tingle inside your foot the day after you fell off the chair while you were changing the light bulb. Was it severe at the beginning, or has it changed since you first noted it?”

These are some patient-centric reasons to document in real time. But there are other reasons, as well.

Clinicians work under tremendous pressure to be productive (more’s the pity) and efficient. As a result, there is no down time during the day - no ‘later’ to support procrastination.  If a gap does appear during the day, it is usually because a patient has failed to appear for their scheduled appointment, and the much appreciated gift of time is promptly spent on urgent clinical messages: abnormal lab, triage messages, and calling consultants and patients. Failing that, there is always an unending pile of non-urgent tasks like prescription refills, pre-certifications and prior authorizations. If I don’t document during the visit, it is easy to find myself with one or even two hours of documentation work on-line from home. In addition to being less comprehensive and accurate, it is considerably slower. Logging on remotely from home is possible but the medical record program accessed this way is painfully slow, enough in and of itself to double my documentation time. It also takes much more time (and effort) to try to remember and recreate the events of a given patient interaction that occurred 8 hours earlier in the midst of a busy day.

Finally, I am fortunate that I am a fair touch typist, though I tend to favor speed over spelling. For this I think my father who made me taking typing in high school. This means I can type without having to stop facing the patient. 

Next time you are tempted to be irritated by a clinician who is typing or taking notes during your office visit together, remember the benefits.



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