Checklist For Your Patient Record

Is the order clear?

Do the data included contribute directly to the assessment?

Are pertinent negatives specifically described?

Are there overgeneralizations or omissions of important data?

Order is imperative. Make sure that future readers, including yourself, can easily find specific points of information. Keep the subjective items of the history, for example, in the history; do not let them stray into the physical examination. Did you . . .

■ Make the headings clear?

■ Accent your organization with indentations and spacing?

■ Arrange the Present Illness in chronologic order, starting with the current episode, then filling in relevant background information?

You should spell out the supporting data—both positive and negative—for every problem or diagnosis that you identify.

Often portions of the history or examination suggest that an abnormality might exist or develop in that area.

Examples: For the patient with notable bruises, record the "pertinent negatives," such as the absence of injury or violence, familial bleeding disorders, or medications or nutritional deficits that might lead to bruising. For the patient who is depressed but not suicidal, record both facts. In the patient with a transient mood swing, on the other hand, a comment on suicide is unnecessary.

Remember that data not recorded are data lost. No matter how vividly you can recall selected details today, you will probably not remember them in a few months. The phrase "neurologic exam negative," even in your own handwriting, may leave you wondering in a few months' time, "Did I really do the sensory exam?"

Is there too much detail?

Avoid burying important information in a mass of excessive detail, to be discovered by only the most persistent reader. Omit most of your negative findings unless they relate directly to the patient's complaints or to specific exclusions in your diagnostic assessment. Do not list abnormalities that you did not observe. Instead, concentrate on a few major ones, such as "no heart murmurs," and try to describe structures in a concise, positive way. Examples: "Cervix pink and smooth" indicates you saw no redness, ulcers, nodules, masses, cysts or other suspicious lesions, but the description is shorter and much more readable. You can omit certain body structures even though you examined them, such as normal eyebrows and eyelashes.

Are phrases and short words used appropriately? Is there unnecessary repetition of data?

Omit unnecessary words, such as those in parentheses in the examples below. This saves valuable time and space. Examples: "Cervix is pink (in color)." "Lungs are resonant (to percussion)." "Liver is tender (to palpation)." "Both (right and left) ears with cerumen." "II/VI systolic ejection murmur (audible)." "Thorax symmetric (bilaterally)." Omit repetitive introductory phrases such as "The patient reports no ...," since readers assume the patient is the source of the history unless otherwise specified. Use short words instead of longer, fancier ones when they mean the same thing, such as "felt" for "palpated" or "heard" for "auscultated." Describe what you observed, not what you did. "Optic discs seen" is less informative than "disc margins sharp," even if it marks your first glimpse as an examiner!

Is the written style succinct? Is there excessive use of abbreviations?

Records are scientific and legal documents, so they should be clear and understandable. Using words and brief phrases instead of whole sentences is common, but abbreviations and symbols should be used only if they are readily understood.

Likewise, an overly elegant style is less appealing than a concise summary. Be sure your record is legible, otherwise all that you have recorded is worthless to your readers.

Are diagrams and precise measurements included where appropriate?

Diagrams add greatly to the clarity of the record. Examples: Study the examples below:

Diagrams add greatly to the clarity of the record. Examples: Study the examples below:

Particle Deflection Field

To ensure accurate evaluations and future comparisons, make measurements in centimeters, not in fruits, nuts, or vegetables. Examples: "1 x 1 cm lymph node" versus a "pea-sized lymph node .. ." Or "2 x 2 cm mass on the left lobe of the prostate" versus a "walnut-sized prostate mass."

Is the tone of the write-up neutral and professional?

To ensure accurate evaluations and future comparisons, make measurements in centimeters, not in fruits, nuts, or vegetables. Examples: "1 x 1 cm lymph node" versus a "pea-sized lymph node .. ." Or "2 x 2 cm mass on the left lobe of the prostate" versus a "walnut-sized prostate mass."

It is important to be objective. Hostile, moralizing, or disapproving comments have no place in the patient's record. Never use words, penmanship, or punctuation that are inflammatory or demeaning. Example: Comments such as "Patient DRUNK and LATE TO CLINIC AGAIN!!" are unprofessional and set a bad example for other providers reading the chart. They also might prove difficult to defend in a legal setting.

Your institution or agency may have printed forms for recording patient information, but you should always be able to create your own record. The record of Mrs. N may be longer than what you might see in patient charts, yet it still does not reflect every question and technique that you have learned to use. The amount of detail varies, depending on the patient's symptoms and signs and the complexity of the clinician's diagnoses and plans for management.

Generating the Problem List. Once you have completed your assessment and written record, you will find it helpful to generate a Problem List that summarizes the patient's problems for the front of the office or hospital chart. List the most active and serious problems first, and record their date of onset. Some clinicians make separate lists for active or inactive problems; others make one list in order of priority. You will find that on follow-up visits the Problem List helps you remember to check the status of problems the patient may not mention. The Problem List also allows other members of the health care team to review the patient's health status at a glance.

A sample Problem List for Mrs. N is provided on the following page. You may wish to give each problem a number and use the number when referring to specific problems in subsequent notes.

Date Entered

Problem No.

Problem

Date Entered

Problem No.

Problem

8/30/02

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