Reflections on paper charting

Jeffrey Gluckstein, M.D. 

Resident in neurology at BWH/MGH

PGY-3

February 15, 2019

I’ve only worked in the era of electronic medical records. I’ve heard older physicians complain about the transition to computerized record systems and agree with their frustrations with the lack of interoperability and the emphasis on billing. That said, I always suspected that the complaints stemmed primarily from the difficulties of using a new system and couldn’t image using a medical record that wasn’t (somewhat) searchable and accessible anywhere.

Working with paper records has turned me into an evangelist for electronic systems. While the paper record system in Zambia isn’t optimized, working on paper introduced me to some unavoidable problems with paper charts.

Perhaps most importantly, paper charts can only be in one place at one time. Usually, that place is the bedside or a nursing station. Sometimes it’s a patient’s home. Occasionally, it’s somewhere unknown. While having to search for a patient’s chart or walk to the bedside to figure out what other teams are thinking may seem like a mere annoyance, it actually changes how much one can do. I spent about 30 minutes a day looking for charts or rewriting lost notes. For patients whose old charts were completely lost (that includes scans, medication records, and notes), we’d have to rely solely on patient and family history. Unfortunately, those histories are often very different from what actually happened to a patient.

Secondly, the stereotype about doctors’ handwriting is true. While many physicians write absolutely beautiful notes, illegible writing made some doctors’ evaluations completely unusable (including my own, initially). While this is solvable in principle with good penmanship, typing or dictation solves it in practice by converting all characters into the same, legible print. 

Finally, manipulating data in paper charts is incredibly slow. While I could painstakingly turn through a 100-page chart to see how a patient’s lab values responded to changes in medication over time, in practice it’s nearly impossible. Pages can be out of order, lab values can go missing, there’s no way to search for when medications were changed, and I often can’t read the notes I need. This leads to a more “impressionistic” evaluation of trends over time.

Older physicians in the US complain that electronic medical records encourage people to cut and paste from old notes. That’s completely true. It leads to the bloated and occasionally inaccurate but easily billable notes written by most residents in the US. I thought that paper notes might solve that problem, but people still copy past notes. Sure, the notes aren’t as long, which makes it easier to focus on the important parts. Unfortunately, they are just as easily filled with incorrect diagnoses from the past (sometimes due to incorrect transcriptions of unclear handwriting).

Of course, there are some virtues to paper notes. Having the chart at the patient’s bedside gives me more time with the family, so they can think of more questions and I can add to my examination if I think of additional testing while writing my note. My slow handwriting forces me to be succinct with my notes (though I’d probably get faster with time). And, in a country with limited infrastructure, occasionally unreliable power, and limited funds, paper charts are cheap and easy. Maintaining the workstations required to run an electronic medical record seems out of reach in a place where the lab regularly runs out of reagents for common tests. I wouldn’t change the system here, but I’m much more appreciative of the clunky, bloated electronic record system I use in Boston.