Sunday, October 11, 2009

Why not let patients make notes in their own medical charts ?

Medical charts are the property of the hospital and have been jealously guarded by the medical staff, most of whom will not even let the patient look at them.

I think this is a big mistake.

The chart is a record of the patient's clinical course during the hospital stay. Since it's all about the patient, why not allow the patient to make his own notes ( if he wants to ?)

One of the purposes of the chart is to allow communication between the medical team members. The patient should be the most important part of the team - why lock him out ?

Some staff members may worry that patients may not understand what is written. Yes, this is possible, but it's far better to tackle this proactively and to use this as a teaching opportunity, rather than to assume that the patient understands what is going on, when in reality he does not have a clue !

The other concern is that patients will become more apprehensive after reading the medical notes. Yes, this can happen, but only patients who want to confront the truth will want to read their notes - not everyone will ! These patients are mature enough to handle the truth - after all, they want to know what's going on with their bodies , which is perfectly reasonable !

Is all this candour and openness likely to increase the risk of malpractise claims ? Actually, I feel this will reduce the risk. Patients often feel that doctors hide the truth from them. By allowing them to read the notes, we can show them that we are being open and transparent, which provides patients with a lot of comfort ! Why wait till a problem occurs and then allow the lawyer to rip the medical records in open court ? Knowing that patients are reading their own medical charts will make doctors and nurses who enter the notes much more careful about what they eter, which is sensible risk management in any case ! And a jury which knows that the patient had free access to his medical chart is likely to respect the medical care givers for their willingness to share information !

We routinely allow doctors to read the charts of their family members when they are admitted into hospital. Why not extend this courtesy to all patients ? Let's not underestimate their need to know, or their ability to understand !

In fact, I would suggest that there should be a separate section for the Patient, where he ( or a family member) can enter their own notes ! This will allow the medical team to better comprehend what's going on in the patient's mind. This can also be useful for risk management, because it allows the doctor to document that the patient was kept fully informed at all times ! This way, the patient cannot change his story later on !

At present, the only time the patient makes an entry in his chart is when he signs the admission form; and the informed consent form. I am sure we can do a much better job ! In fact, the patient's notes can be great teaching tools as well, because it may provide information which may otherwise be easily overlooked or forgotten !

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