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Recording skills: examining the art form

by
01 June 2017, at 1:00am

GARETH CROSS takes a lighthearted look at the different types of record-keeping one might encounter in practice, from helpful to terrible

“COMMUNICATION SKILLS” IS A PHRASE that is familiar to us all and something that we are scantily taught at undergraduate level and are left to develop, or allow to atrophy, as we progress through our careers. Along with communication could go “recording skills” as in writing clinical notes, referral letters in both directions, staff memos, etc. We’ve had a few cases recently at work that have made me ruminate on this topic and look for some novel solutions. Clinical note-writing is a bit of an art form which can take many guises. Here’s a light-hearted view of a few I have encountered in what is coming up to 20 years in practice.

Someone who appears to
have been taught to do it
properly

We have one of these in our practice now and it is always a pleasure to read the clear notes, not too brief and not too long, broken into sections. These are H for History, something beginning
with A which I have never worked out but I am guessing is Assessment, and P for Plan. This approach helps make the
important differentiation between what the owner tells you, H (“he’s lame on the right leg”, for example), to what is actually evident on clinical exam (“7/10 lame L fore”). In most practices where vet continuity is not 100%, it is crucial to record what has been advised to the owner so the next vet can follow the same approach. This avoids confusion and having to appear to disagree with a colleague or even, depending on your age and memory, arguing with yourself about what you said last week. It is also vital for any style of note-taker to record advice given by the vet (or receptionist on the phone) and not taken or refused by the client.

The Haiku Master

This is a common style in older vets who have seen and done it so many times before, they just jot a few choice words down but know exactly what they mean, and importantly so does the next person reading the notes as long as you have all worked together
for a while and know roughly how they work. An example of the style I might use could be something like “D+v 2d GPE NAD adv usual”. This, along with a record of treatment dispensed, I could legitimately upscale into a 500- word essay. Anything outside of the parameters of “GPE NAD” would be separately recorded and by its absence in the notes it can be assumed was not present in-vivo. The vet I succeeded at my current practice employed this style almost exclusively, but we always knew what he meant.

The Expert

This often applies to a GP vet who has a favourite subject or certificate. It will usually lead to a departure from their usual style and generate a paragraph or two which is completely unintelligible
to anyone else in the practice.

No notes at all

Often a style employed by practice owners. Just as their fingers hit the keyboard a line of people appears at the consult room door with questions about subjects ranging from lifethreatening emergencies to the pension scheme. The train of thought is lost
and the notes are forgotten. My personal favourite was when
trying to type (it was actually an insurance claim) I was interrupted numerous times and finally someone just plonked a cardboard box with an injured bird in it on the keyboard and walked off. Colleagues of the “No notes at all” vet need to develop a certain set of skills to be able to do re-examinations. I find nice open questions are good for discovering what may have been said and done last time, like: “How’s it going?” or “Just recap in your own
words the timing of it all.” These are also useful in dealing with cases sent to you for a second opinion when you have yet to receive the notes about the first opinion. The advantages of having no notes are few, but the main one is stopping insurance companies going on a fishing trip for exclusions in annual policies.
Some insurers are getting very sharp at picking up on any casual remark in historic notes and slapping a lifetime exclusion on it.

The Essayist

The opposite of the above, and sometimes almost as difficult to follow on from. So many whys, wherefores and what-ifs have been debated that it is hard to know what actually was decided. However, this style of writing will record everything that was done,
suggested and not done, etc. Elements of the “Doing it properly”
style and “The Expert” are evident in these notes. If ever notes are needed in a medico-legal setting then this will cover everything and probably even convey something of the atmosphere and how everyone felt during the consultation. 

The Randomiser

I think this is sometimes what I end up producing. As the client leaves the room, I start typing in a stream of thought that has no real timeline or structure. It’s usually all in there, but not very logical. Frequent;y scabttered with typgrahpicsl errors as the fingers cant keep uop with hthe brian,. Pondering such things led me to wonder if there was a “black box recorder” we could install in the consult rooms to record what was really said. Clients often forget what was said by the time they reach reception and despite me telling them it is “one tablet twice a day with food, start tomorrow morning” and printing it on the label, the receptionist will still often have to confirm it again as the client is “a bit confused”. How much critical information will have been lost by the time they get home? How much confusion will have crept in about what to look for if things are deteriorating? About when to come back? We have all had complaints and often the client’s version of what was said and advised is at variance with what
was actually said. If we are lucky there are good clinical notes to record the gist of a conversation, but not always as we have discussed. I questioned some friends: a GP, community psychiatric nurse, psychologist and a software designer. Firstly it would appear that no such system is in common use. The GP commented that they now do a lot of their consultations over the phone and these  are indeed recorded and kept for three years. Also from some quick research it appears to be becoming more common for GP patients to record actual (i.e. non-phone) consults on their phones. The VDS commented to me that they have also come across this
with vets. The psychologist and nurse felt that as you would have to inform the client the conversation was being recorded, this would immediately change the nature of the relationship and erode trust – essential in their line of work. I think that recording in consults would be a good idea. It would close the gap between our verbal communication skills and our recordkeeping. Based on personal experience and observations, the quality of notetaking
bears no relation to the quality (or sometimes even the contents) of a consultation. Nearly all consults end with the clients satisfied, happy and with a clear plan in place. When the overdue bill
lands on the doormat 30 days later, suddenly that can change. It is then hard to get to the truth if a complaint or law suit comes in and you are defending against a client with very strongly held memories (which may be true, false or confused) and all you have are some clinical haikus, missing notes and random jottings of
an overworked mind to refer back to.