“D” is for Document

by Karen Knops, MD

Proverb: The faintest ink is better than the strongest memory.

As ancestral cave paintings indicate, humans have always had the instinct to create a physical record of events and plans. We mainly think of taking notes or diagramming options, but enduring records of our conversations can take any number of formats, as Electronic Medical Records and smart devices give us new options.

The real work of healing and education is often done in the days and weeks that follow a medical visit – work that is done by patients. Just as students have been shown to retain information better if they review their notes soon after a class, we can make the most of our visit by having something to debrief with afterwards. A clinician ideally establishes a partnership with us that will provide benefits outside the exam room. Bringing the power of partnership to bear requires a way of bringing the ideas from the conversation to the people that matter, such as our families. When we document elements of our plan in our calendars and to-do lists, we shape our future actions. The information we take with us is a jumping-off point for what comes next.

As we discussed above, good “Anticipation” can mean gathering pen and paper, updating our one-page summary, and pondering how our digital devices might serve us are actions that reap benefits during and after our conversation. During the visit itself, it is okay to ask for words or concepts to be written down – for people who use the jargon every day, it is all too easy to give explanations that are impossible to keep up with. Audio-recording important conversations is sometimes an option and more and more clinicians are comfortable with this. There are now specific smartphone apps designed to help us prepare for and record medical visit information, so it is often worth searching for the latest tools. Many organizations have policies about photos and recordings. We want to capture information in a way that everyone agrees is acceptable. When in doubt, ask.

Good information is more than just words – some of the best clinicians draw pictures or use models to describe what is happening in the body, or diagram the differences between treatment options. Even scribbles on a white board or a napkin can become useful information if we grab a photo, or ask someone to take a photo to share with us. Some people prefer to take photos of business cards and signs so the information is captured quickly and can’t be lost. Being mindful about where digital information is stored ensures that our privacy is preserved.

Clinicians typically create notes about their interactions in an Electronic Medical Record system. Sharing that information with others who do not have access to the record system can require specific steps. Taking a moment at the end of a visit to understand when and how documentation will be available can save time and frustration. In some circumstances, clinicians are able to print out specific results or notes for us to take at the end of the visit, but this may not be possible in all cases. Getting our records can require forms to fill out or other processes to get the right information to the right people. Most healthcare systems allow clinicians to create a document called an “after visit summary” that can be printed or shared via patient portals to recap the plan or highlights from the visit. Because there can still be discrepancies or later additions to the plan, more and more systems allow patients open access to actual clinician notes. If access to records is a major concern, asking at the beginning of the visit can prevent a scramble or disappointment at the end.

Documentation can include printed information or a preferred website to use for reference after the visit, as mentioned in earlier sections, or clinicians can include patient-friendly educational information as a part of the after visit summary materials. Reviewing written information directly with the person who is giving the education or instructions helps us remember and gives us something to refer to in the days and weeks ahead, in addition to giving us a chance to ask specific questions.

Using these documents, images or recordings to debrief after a visit helps us retain the information and ensure we translate it into an action plan. So use that ink, or that digital magic, to give yourself peace of mind and connect with important information.

The one-page health summary

A single page summary of one’s health history can be a great tool, especially if we see many different providers or have a complex history, or are in the hospital or care facility for a prolonged period.  Offering this written summary to a new medical professional can help them focus less on writing or typing and have something to refer to that reflects our actual priorities. A challenge of medical records is that they contain so much detail that the most important items can be hidden – often they don’t tell the real story. Printing out or photocopying a summary before a visit, and writing any visit-specific information on the back can become an “anticipation habit” that helps us feel prepared. The backside of the summary is a great place to add a timeline of new symptoms, test results or data to discuss, and a place to prioritize concerns.

Things to consider including:

  • A short introductory paragraph about your overall health and function, who you live with, and details such as your profession or hobbies, passions, and pets.
  • Challenges you face in medical encounters – hearing loss, a preferred language other than English, memory difficulties, or a history of trauma related to medical care
  • List of diagnoses, ideally with timing of when you were diagnosed and when/if the issue resolved
  • Timeline of prior surgeries and timing of diagnoses
  • List of providers caring for you, including complementary services, like acupuncture
  • List of medications with doses and how often you typically take them.
  • List of supplements
  • Allergies and the type of reaction
  • Family history of major illnesses
  • Your emergency contact, and/or Durable Power of Attorney for Health Care,
  • Answers to FAQ that have been asked of you in the past.
  • A recent photo, and/or photos that show who you are and what matters to you

Read the introduction  and previous posts in the A-S-C-E-N-D series:

“A” for Anticipate
“S” for Summarize
“C” for Concerns
“E” for Explore
“N” for Next Steps