When I was in practice, I used to tease my colleagues, "I want my patients' charts to be so well-organized and thorough that if were struck down by lightning, you could easily take over their care, knowing exactly what I was thinking and planning."
In my mind, the chief purposes of my medical charts -- and it's no accident I've always referred to them as "my" charts -- were (2) to help me provide efficient and high quality care by summarizing and organizing the data and (2) to help others take over should I be unavailable.
In addition to recording the medical history and the findings of my physical examination of the patient, I recorded my differential diagnosis (the list of diagnoses I was considering), my impressions of the most likely diagnosis, my plans for evaluation and my prescriptions and instructions for the patient. Sometimes I even recorded my "Plan B," in case the current treatment was ineffective.
The intense grief I felt over closing my medical practice permanently when my cancer recurred the first time in 1992 was softened just a bit when colleagues told me how easy my charts made it for them to take over the care of my patients.
The medical chart has other purposes, such as providing:
- legal documentation of what was -- and wasn't -- done or said at a patient visit
- documentation for insurers' determination of payment (or non-payment)
- quality monitors
From the perspective of Healthy Survivors, do open notes help or hurt their ability to get good care and/or live as fully as possible? In my next post, we'll begin to answer this essential question.
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