Charting: Factual vs. Fictitious

 For anyone who has ever had the privilege to be exposed to a medical charting system, this post might seem familiar.  This post isn't really about my chart notes being factual or fictitious, it's more about walking that fine line of what is needed to be said and what wants to be said.  Like most hospitals/doctor's office/etc, this hospital uses a note-taking system that allows for everyone who interacts with patient to document it. 

 

The system here is named...

 

wait for it...

 

 

 It is, of course, epic.

 

 Everyone uses it.

 

Doctors, x-ray technicians, nurses, OT, PT, and yes, even Chaplains.

 

Especially Chaplains.  Our use of the epic system varies quite differently than our medical peers.  Instead of doing medical assessments, we do spiritual assessments.  (It's not as intense as it sounds, I promise.)  Praise the Lord, our charting requirements are much simpler than our cohorts.  (We were able to knock out our system training in under two hours.) 

 

I find the charting sometimes quite hard to do.  When I was in pre-surgery, and I visited on average 10-15 patients each morning, and most of them before 7:00am.  I didn't chart until an hour (or sometimes 4 hours) later, and developed a note system to helped me remember everyone I'd met with. It involved many colors of pens, dots and dashes, and random one word reminders, that anyone else looking at it would say, "What?", but I look, and go, "ahh, yes".

 

Then, when it's time, I would come back to an office, sit down, and try to chart our visit. 

And that's where the trouble starts. 

While I could easily copy and paste a note for everyone I've visited, I just can't do it.  I feel like if anyone, I'm the one person, who in charting, should put a little piece of the patient in the chart - and not the details of age or sex or medical issues - but a bit of who they truly are - a loving mother, an anxious spouse, or hilarious grandma. 

 

This might be my English degree sneaking in, too.  Charting is very impersonal, all said from 3rd person perspective.  I, of course, find myself writing sentences that could be the beginning sentences of a soon-to-be-smashing-hit novel. (emphasis on "could be")

 For example, this is what could be considered a general note used for a patient:

  

Met with patient and family; introduced them to Chaplain Services. Patient expressed he was a little anxious, but felt supported by friends and family. Offered pastoral support. Will continue to provide support and follow up as needed.

 

Here is what I wish I could say:

 

Walked into the patient's room, and patient looked up nervously, as if anticipating yet another person walking in to take something from him - his blood, his temperature, or his signature. Yet as I introduced myself, relief flashed across his face.  I walked farther into his room where his friend greeted me with a genuine smile, one that touched all the corners of your heart and just oozed kindness and warmth.  Addressing the patient, I went through the "pre-surgery" routine, which often times felt like a one-woman-stand-up comic relief type of show.  I informed him there were people here at UTSW who wouldn't ask for anything from him, but would offer what they could for him - a kind smile, a prayer spoken, or the opportunity to kick someone out of the room.  Patient expressed how much it meant to have his friends and family along side him in the room where he felt over exposed and how their presence made him feel normal.  Patient had a great laugh and you can tell this is a group of friends and family who tell each other they are loved.  It was an unexpected blessing to visit with them on this early summer morning; a reminder of our God at work in what may seem a mundane morning, but sacred all the same

Here's another example.  Something like this gets charted:

  

Met with patient and visitor; introduced them to Chaplain Services. Patient expressed no needs at this time; will continue to follow up and provide support as needed.

 

And here is what I wished I could say.

 

Walked into patient's room, and the sense of inconvenience of the entire sitution was speaking louder than the bright yellow gown draped around the patient's shoulders. I introduced myself to the patient who exclaimed within the first few seconds confirmed she was "fine" and needed no assistence from Chaplain Services.  Eye-contact was somehow avoided the entire time I spent with the patient and visitor, as was the mention of the reason for the patient's visit.  I wanted to share with the patient she was not alone in having her life interrupted or inconvenienced by the aggresive monster named Cancer. I wanted to let her know that it was ok if she was not fine.  But I put my wants away and let the patient know Chaplain Services was available at her disposal, and left her room. 

 

I wouldn't say it's an internal battle, but sometimes it's hard to truly capture what happened in the moments I spent with a patient in their chart. I know there is a good reason to remain objective within the charts, but it still feels like we're treating an object, and not a person.  And that's where the little Chaplain notes can make a difference.  I can make a comment that this patient gets much meaning out of being called grandma, or that this patient's from out of town, but has a strong support system here in town.  Do the doctors or nurses or therapisits read any of these notes?

 

Maybe. I mean, I hope so.  And I hope it offers something to the story of this patient.  I hope it gives the doctor/nurse/caretaker pause, maybe a reminder for some that this is a beloved grandfather.   

Or that it clues them in that this patient has no strong support systems to share in the grief of a terminal diagnosis. 

 

There ARE many health professionals who treat patients as more than just a Medical Reference Number or new diagnosis.  But Chaplains can sometimes fall in a weird gap of meeting patient's needs.  We often have met with family and somehow have acquired little nuggets of knowledge that maybe no one else had thought of. This is not because the others don't care, but when I meet with a patient, I don't have any medical jargon going on in my head - I am there, face to face, with the patient.  Or the family as the case might be. 

Sometimes I laugh with families as they remember funny jokes. Sometimes I pray, sometimes I listen to a prayer, and sometimes I leave with a blessing. Sometimes I just walk people to the right set of elevators. Sometimes I listen to patient's share their journey to this time and place.  Sometimes I direct people to the best cup of coffee in the hospital. Sometimes I weep with families as they walk through the shadow of the valley.  Sometimes I give hugs and talk about alligators with a 7 year old who has a dad dying of brain cancer.

All of these "sometimes" are important, and some seem monumental.
 All are a part of a patient's journey here at the hospital.

And when I'm done, I come back to the office and condense the visit into a succinct, somewhat impersonal but always factual chart note.

And then I hope the empathy felt, the emotions noticed, and the little peices of information gleaned prove to be represented well within the note.