One of the things that I do a lot of in my work is make notes. Okay, I take that back: it’s the majority of what I do. Throughout a doctor’s day, almost 50% of their time is spent documenting their decision making and doing related paperwork. Considering we divide the rest of our day into reviewing charts, prescribing medicine, and seeing patients that’s why I say it’s most of what I do! In anesthesia, we have to document everything from the medicines I give, to the fact that I taped the patient’s eyes to protect them, to the time I went in the operating room and left it! During surgery, I’m constantly updating the “anesthetic record:” blood pressure, temperature, patient’s position, ECG rhythm, and much, much more.
Documentation serves its purpose, and it demonstrates yet another example of shifting perspectives to learn about oneself and one’s work. Unfortunately, these shifts can lead to misunderstanding,
Medical record keeping at its finest...
misinterpretation, and misuse of the data that such documentation provides. The end result? It’s another way that we fall short of our possibilities. Instead of making us better, it threatens us. We have then have to spend our energy on the document, or protecting ourselves from the document, becoming a slave to it and being less able to focus on the care of the patient!
Let’s imagine why all of this exists. I suspect that very early on in the process of learning to do something well, people figured out that recording their actions in a systematic way would help them go back and improve their performance. DaVinci and others like him come to mind here, but obviously it started far before that. Surely, no one knew immediately what to record and how often to record it. So some times there was too much recording–maybe it got distracting, or the work itself suffered. At other times, too little was recorded and those looking back wondered what happened. Through a process of trail and error, though, a pattern of record keeping emerged intended to create an insightful and useful history of an event. As people sought to emulate those before them, it became clear that an efficient way to pursue knowledge included documentation.
I imagine some other point people started to look at the documents as an entity in and of themselves. Instead of just having a record, people started to see that other things could be gleaned. For instance, documenting something every few minutes served as a reminder to check on that parameter consistently. Also, some data helped corroborate a story when someone tried to piece together what went wrong in a bad out come. Even more, certain information could show patterns, a forest view of individual experiments.
Suddenly, documentation became a tool with its own life; instead of using it to simply record things with their own goal, it started to have its own goals! The conclusions derived from this outside-the-box or forest view of data helped streamline the work process itself. In a sense, instead of just a one-way historical record, data became a conversational historical record. Actions create documentation, but now documentation also created action.
To an extent, this was great because it helped us improve systems. But in our current health care system, things can go too far.
As I mentioned, now the record takes up the majority of the day. Because of the expectations that the record creates, I have seen people “fudge” the anesthesia record, surgical record, or whatever records are being made. Is that really the time the antibiotics were given, or is that the time documented because a policy was created based on the data pool and we need to meet that policy’s obligation and avoid chastisement? When things go to the point that the record is no longer accurate, certainly we need to re-evaluate our situation–conclusions based on false data are dangerous!
How did this happen? I suspect that when we started looking at the data outside the context of the work we do that division created unnatural pressures. We looked at goals within the work process instead of the overall goal. While it helps to improve the parts we look at, it also makes us focus on those trees too much–sometimes to the point of creating issues. For instance, surgeons don’t like to have high blood loss because it’s a data point associated with criticism when taken out of context. But instead of facing the music, they will bicker over blood loss so the document shows less. This leads to inaccurate assessment of blood loss. If you’re underestimating how much blood your patient lost, don’t you think that’s dangerous for the patient? And yet…
JCAHO is an entire governemental overseer for hospitals largely based on documentation. Where do you think all of our legal issues in health care come from? Lack of documentation is a key component of malpractice. Does the pressure of meeting the demands of these overseers and legal threats cause us to change our records, or pressure us to focus more on the record than necessary? See the example above…(and note, is it just the surgeon’s fault? They get credit for not having antibiotics in time, but if the anesthesia team forgets to put them in, the surgeon still gets blamed…)
I think the pressures of the record are causing problems. In addition to the examples above, I’ve seen records improperly done, I’ve felt or been the pressured to curve numbers in the better direction, I’ve been told time and time again about documenting lots of random facts for legal reasons. The document that began as a helpful adjunct to becoming a better physician or doing work better (or scientist or whatever) now demands its own respect. When something gets to the point that it leads to inaccurate documentation to avoid repercussion, it is also likely taking time away from patient care–wasn’t that the point of this health care in the first place? It’s a tragedy to think of the inefficiency that develops from the pendulum swinging in the direction of the document.
Then there’s the legal aspect: a concept that if it’s not written down it didn’t happen. It is ridiculous. Not only is that simply not the case, but I’ve just mentioned above the worst flaw: I can write down things that didn’t happen. Then where do we go? Back to our oral tradition?
Can we stop the documentation from getting out of hand? It’s probably too late. Too many people’s jobs depend on documentation now. It would take someone to remember what we originally did this for, and then to realize the negative impact that this entity brings to a system. Seeing this disparity, that leader would then have to find a way to turn all those people currently using documentation improperly into people who turn the system around in a positive direction. Not likely to happen with the unrealistic expectations that are out there. Change the expectations? Sorry, they come from people analyzing data points on a record that is becoming less-than-accurate as we know. Many times those people have a business or legal background; people without the background of the context in which the documentation was meant to be interpreted might have unique insights but they can also have uniquely wrong opinions about what they see.
Forgetting the context (the forest) of documentation is the culprit, so naturally remembering the context is the solution. I can use the patient’s old operating record to know if there were problems with their last surgery and be aware of those for this one. I can use an old record to analyze with one of my elders and learn how to do things better. I can see trends in the patient that I couldn’t otherwise see that help me make decisions during a surgery. Finally, I can take data like surgery times, etc, to make my practice better. However, all of these things are within the forest I’m looking for: how to take my patient through the surgery more safely and use our resources effectively. It’s here–where the document’s goals and my work’s goals are juxtaposed with an overarching goal in mind–that we will see, hear, and do what really matters.
