I went to echart training tonight to prepare for my hospital's switch to electronic health records. During the session, I was excited about the potential of echarts to improve access to information for healthcare workers and patients. I am excited to not have to search for pt. charts and then struggle to read MD chicken scratches.
The rehab charting featured lots of check boxes, scroll down lists and fill in the blanks to increase speed of documenting. But even as a relatively new practitioner, it all made me nostalgic for the character and narrative of the handwritten SOAP note. I love how narrative notes tell the patient's story and the story of treatment sessions. It is truly an art form to discern what needs to be said, what can be left out, and to come up with the choice words needed.
I recently read God's Hotel by Dr. Victoria Sweet. I resonated with how she described fellow doctors by explaining their handwriting and note writing style. One MD she describes had concise, neatly handwritten notes. She gives an example of one of his notes, which would never fly as documenting skilled service, but perhaps says all that needs to be said.
Mr. G was terminal; he was to have hospice care;
his family has been contacted; he was at peace.