The Irish Medical Times - Should charting be objective or subjective
she had taken it upon herself to make a note in my chart that I was “A very anxious lady”. I asked the hospital to remove the note as I was not an anxious person, the hospital declined to make the change.
I don't mind what people think of me or observe, but I am uncomfortable being told how I feel (only a person themselves knows how they feel - in that phone conversation I was not an anxious person but a person frustrated with delays, lack of communication and mis-communication). In a court of law telling a person how they feel is inadmissible, I would apply the same logic to a medical file. In this circumstance I found the descriptor prejudicial.
My gripe may seem neither here nor there but what is written in our patient file will be read by the next doctor and nurse and inform their opinion of us. It can throw doubt and disbelief (dare I say hysterics) over a genuine physical or even psychological problem (or even a legitimate complaint of care). For the record, I was fine with references in the file from real medics regarding how I am coping (anxious or well), their comments were written as contextual observations having actually treated me in person, usually over a prolonged period.
In another letter from a different hospital a doctor noted that he had spoken to his colleague about me and that I had told her I had a family history of cancers, which explained why I had succumbed to more than one cancer. I don’t have a remarkable family history of cancer, I am aware of the doctor he is talking about and I didn’t have that conversation with her. My second cancer is directly related to the treatment from my first cancer, it’s not familial or genetic. She may have been thinking of a different patient - but now the untruth is on my file.
Everybody is human and errors happen, but these errors pertain to our health. A series of medical notation errors can erode the trust we have in those looking after us.
I think it's sad in a way that our medical file, a tome dedicated to us, doesn't bear a whisper of our own voice.
With improvements in GDPR and freedom of information patients are getting access to their notes so I imagine the note makers are bearing this in mind when they ascribe something to a file. After every appointment, test, scan, etc I ask for letters, reports, and whatnot. I then review them myself. In fairness, it’s seldom that I see a mistake, but occasionally I do.
While vitals, lab results, and imaging are generally considered objective, even their interpretation can have a subjective element.
In recent years I had a radiologist describe a bone break as due to my fragility. There is nothing fragile about me, it was due to an accident. If he had looked at my recent DEXA he would have seen these bones ain’t made for breaking. I’m guessing he just looked at my age and thought, female over 45, I’m surprised she can walk down the road without snapping like a twig.
Nonetheless, I appreciate it would be cumbersome and a logistical nightmare to have patients proof read every letter, comment, note that goes on their file.
Enter AI.
I haven’t seen this yet in Irish hospitals but in certain American hospitals there are AI medical scribes at work that can note what the patient is saying, what the doctor is saying, and how it relates back to the scans on file. They can even put together a summary. Perhaps the patient, as well as the doctor, could have permission to sign off on the summary. It could be done via an app in your own time.
I don’t believe AI should replace or supersede our healthcare professionals. There is an art to medicine that you can’t programme into a machine, and this art will involve subjective judgement. But medics working alongside AI adds an assistant to the process, capturing the facts accurately and keeping in play the patient’s perspective. A doctor's clinical impression is also something that is subjective but we should respect that as an expert opinion. My concerns are errors and inaccuracies logged into a file that over time become an unchallenged fact.
If a doctor felt a patient would be reviewing their notes would they start having official notes and unofficial ones? Perhaps nobody has time for that level of skullduggery, although, if one were to create a medical app for these illicit whispers, you could call it ‘Skullduggery’ - I’d download that.
Also, pressing record on a conversation may take away the chat and banter that a doctor and patient may enjoy as part of their natural bonding and trust building. Of course all visual cues will not be captured by AI (not yet, at least).
But as an accurate record keeper and reliable fact checker, AI has got it going on.
Perhaps the ideal AI solution would be for the computer scribe to fact check the latest meeting summary to all of the patient’s file history and flag any inconsistencies e.g. the patient or doctor has noted no family history of diabetes, prior notes show a family history, and so on.
I think AI should assist and not replace humans. I don’t want a computer diagnosing me, but I would feel comfortable if AI threw together a summary of my visits with doctors. I’d even let the doctor have the first shot at reviewing it, adding/changing/deleting as they see fit. Then over to me for my sign off.
Perhaps, the bigger question is, if AI makes a mistake, and both doctor and patient sign off, ultimately who then takes the responsibility for the error?
I’m pointing out AI as the solution but beneath it all I am calling for a more collaborative and transparent approach to medical note taking. Accurate records are not just for the patients benefit but for the integrity of the healthcare system as a whole.
Also, people don’t appreciate being told how they feel, let alone seeing it in paper years later. If you think someone is anxious, instead of scrawling that in their file, maybe ask them how they feel and why. Don’t be alarmed if they answer that your AI scribe is stressing them out. Nobody likes an earwig (another great name for a scribe app).
Whether we go the AI route or start working together, it’s time our medical records told our story, not someone else’s.
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