Last week at the clinic, I was assigned the job of updating the summary page of the Electronic Medical Records to match the paper and virtual notes of the providers. There are numerous benefits to having an up-to-date summary page on each patient, with the greatest being time efficacy for the provider, but the better organization could also lead to decreased safety risks. Either way, eight hours of reading/updating charts from a variety of providers opened my eyes to how variable a patient note can be from one health care provider to the other. So I began to ask myself, "What can providers do to produce a high quality patient note?"
In an attempt to satisfy my curiosity (and take a break from the charts), I followed Molly Paulson, PA-C and Director of Admissions at Grand Valley State University's Physician Assistant program, into a patient's exam room.
After 'vital signs, an ECG, glucose check, patient history, and a full exam were completed, we headed to the back room to create the note from the patient visit. The basic layout, Molly explained, can be remembered using the mnemonic, SOAP, which stands for Subjective, Objective, Assessment, and Plan.
Subjective: is more or less the reason that the patient decided to come to the clinic: "It's the patient's story", Molly summarized.
Objective: is "My story", or the provider's story. This information is based upon the facts and findings of the provider: vital signs, lab results, measurements, and any other findings from the examination
Assessment: "What we (the providers) think is going on [with the patient]." AKA the diagnosis of the patient
Plan: "What we (the providers) are going to do about [the patient condition]." The plan includes any medications the patient will be started on, what recommendations were given to the patient,and when follow-up appointments should be, if needed.
The SOAP mnemonic is great; I am glad I get to familiarize myself with it, but it only accounts for the general order of the note, not the style or quality of content. So I read into some tips from the providers and did a little internet research on top of it. What I found left me very pleased.
Thomas Robey, MD, PhD in the Emergency Department at Yale-New Haven Hospital wrote an article in 2011 for the American Medical Association titled, "The Art of Writing Patient Record Notes", and in it he wrote,
Thomas Robey, MD, PhD in the Emergency Department at Yale-New Haven Hospital wrote an article in 2011 for the American Medical Association titled, "The Art of Writing Patient Record Notes", and in it he wrote,
"...the best physician documentarians are great story tellers."
He continued, "For millennia, humans have told stories to make sense of the world around them. Tapping into that tradition will enrich physicians’ notes, and may even improve patient care." This is great news for me: my family, friends, or anyone who has spent more than a few hours with me will attest to the fact that I love to tell stories. Stories have structure, they are entertaining, and, most importantly, they help me remember.
After talking to the providers at Oasis of Hope Center and countless other Physician Assistants (PAs) that have crossed my path, they all seem to reinforce the idea that their clinical years of school were the years they retained the most information from. I believe this has a lot to do with the element of story that is associated with patient cases. Even Rudyard Kipling once said...
After talking to the providers at Oasis of Hope Center and countless other Physician Assistants (PAs) that have crossed my path, they all seem to reinforce the idea that their clinical years of school were the years they retained the most information from. I believe this has a lot to do with the element of story that is associated with patient cases. Even Rudyard Kipling once said...
"If history were taught in the form of stories, it would never be forgotten"
Now that may say it all, but in case you still do not fully understand the point I am trying to get across, let me finish with an example of how story has solidified a tidbit of information into my head:
A few years back, a man walked through the front doors of Oasis of Hope Center who was described by the provider that day as a "bag of bones." This man's name is Kenny, and he not only permits, but encourages the sharing of his story.
Kenny was serving out the last weeks of his prison sentence when he, and everyone around him, became very aware that something was not right concerning his health. The fear of the prison environment, however, discouraged Kenny from accepting any medical care, but he knew he would need help as soon as his sentence had concluded.
After arriving at Oasis, Kenny presented with weakness, fatigue, and claimed to have a decreased appetite. His description and examination showed signs of possible nerve damage as well: he was in rough shape. The clinician believed pernicious anemia was one of the diagnosis he needed to address, and he inquired about any available vitamin B12 that may be at the clinic. Unfortunately, we did not have any at the clinic at the time of his clinic.
Pernicious anemia is the inability to absorb vitamin B12 from the GI tract. Since vitamin B12 is needed to make red blood cells, a lack of B12 can lead to a lack of red blood cells. This would causes decreased oxygen to the tissues of the body (including nerves), and that results in weakness, fatigue, and can, over time, result in nerve damage. It explained most of this patient's condition.
The clinician finished seeing Kenny and provided him with any medications/prescriptions/care that was available, but not B12. This may have been a problem since Kenny did not have a lot of money to work with, but within a few hours of Kenny's departure from the clinic, a shipment of donations came in that contained none other than vitamin B12.
With the help of that initial vitamin supplement and the care/advice given to him, Kenny recovered physically and mentally. After his recovery, he returned to Oasis of Hope with a request that the director, Barb, join him at church sometime in the future. The reason? He wanted her to be there the day he preaches his first sermon: he was going to go back to school to be a "preacher man."
Kenny was serving out the last weeks of his prison sentence when he, and everyone around him, became very aware that something was not right concerning his health. The fear of the prison environment, however, discouraged Kenny from accepting any medical care, but he knew he would need help as soon as his sentence had concluded.
After arriving at Oasis, Kenny presented with weakness, fatigue, and claimed to have a decreased appetite. His description and examination showed signs of possible nerve damage as well: he was in rough shape. The clinician believed pernicious anemia was one of the diagnosis he needed to address, and he inquired about any available vitamin B12 that may be at the clinic. Unfortunately, we did not have any at the clinic at the time of his clinic.
Pernicious anemia is the inability to absorb vitamin B12 from the GI tract. Since vitamin B12 is needed to make red blood cells, a lack of B12 can lead to a lack of red blood cells. This would causes decreased oxygen to the tissues of the body (including nerves), and that results in weakness, fatigue, and can, over time, result in nerve damage. It explained most of this patient's condition.
The clinician finished seeing Kenny and provided him with any medications/prescriptions/care that was available, but not B12. This may have been a problem since Kenny did not have a lot of money to work with, but within a few hours of Kenny's departure from the clinic, a shipment of donations came in that contained none other than vitamin B12.
With the help of that initial vitamin supplement and the care/advice given to him, Kenny recovered physically and mentally. After his recovery, he returned to Oasis of Hope with a request that the director, Barb, join him at church sometime in the future. The reason? He wanted her to be there the day he preaches his first sermon: he was going to go back to school to be a "preacher man."
The story of transformation alone is worthy of being remembered, but as a student who only gets the medical glimpse into this tremendous story, I will always take away an added component: I'll never forget pernicious anemia or the vitamin B12 that helped that "bag of bones" go from prison to pulpit.