Some advice from a college supervisor.
Written by Dr. John Crosby on June 25, 2019 for Canadian Healthcare Network
Reprinted with permission.
From 2Ascribe: You might also want to consider using a medical transcription company to help with your charting. Most people can talk 3 times faster than they type and 10 times faster than they can write. By dictating, you can accomplish more in a shorter period of time, with the added benefit that it’s completely legible!
This article first appeared in Canadian Healthcare Network on June 25 
2019. You can link to it at http://www.canadianhealthcarenetwork.ca/physicians/discussions/blogs/kindly-country-quack/how-the-college-wants-you-to-chart-56432?utm_source=EmailMarketing&utm_medium=email&utm_campaign=Physician_Newsletter
The Kindly Country Quack
by Dr. John Crosby
This is my own personal opinion based on my experience. I have been a supervisor for the College of Physician and Surgeons of Ontario for four family doctors and have rendered opinions for the CMPA on three other doctors with charting issues.
Electronic Medical Records
I recommend you get one. They are far better than paper charts for legibility and security. They help you keep better track of prevention issues and help with consult letters, off work notes, reminders and drug allergies.
Demographics
Include the patient’s name, address, health card number, birthdate, gender, family doctor or nurse practitioner, pharmacy, cell phone and email.
Family history
This is a big one because if your dad died of an MI at age 45 it is very significant, unlike if he had died at 95. Also inherited diseases like colon and breast cancer are important to note for screening.
History of past health
Just the highlights here. One doctor I worked with recorded every visit here, which made it so detailed that it was useless. Also add the specialist’s name they saw so you can send them back there if the patient desires it. e.g. MI 2015 Dr. Smith, Cardiologist.
Treatment
This is mostly the drug list. Make sure you get rid of the drugs the patient is no longer taking. I get my multi-problem patients to bring in all their drugs with every visit and update their list with them and their caregivers.
Allergies
Put what happened, e.g. anaphylaxsis. Vomiting on narcotics is usually dose related not a true allergy. I have had patients tell me they are allergic to adrenalin because it made their heart race.
Immunizations
This should include the lot number of vaccines in case there is a recall.
Reminders
e.g. the patient needs a tetanus shot, colonoscopy, etc.
Personal history
This includes job, cigarette, alcohol and illicit drug use. I also put what kind of insurance plan they have or if they have a government drug plan for seniors or welfare.
Use “SOAP”
Use the SOAP form: Subjective, Objective, Assessment and Plan.
I use templates but I fill them in in detail. I use them as a prompt. For example with babies I use the Rourke Baby Scale which lists all the milestones and reminders for each age.
For opioids I do a full targeted history and physical each visit. A lot of doctors get into trouble when the chart reads:
May 1, 2018 Percocet 100 tabs
June 1, 2018 Percocet 100 Tabs
July 3, 2018 Percocet 100 tabs
August 2, 2018 Percocet 100 tabs
It should read:
Subjective: back pain for 3 months in lumbar area. No night pain, no radiation. Feels like muscle spasm. Has tried Advil and heat.
Objective: spasm in lumbar area, normal range of motion of the spine, reflexes 2 + and equal, straight leg raising is normal. Pain rating is 5 out of 10.
Assessment: muscle spasm lumbar spine.
Plan: physio, heat, ice, exercise
I also do a narcotic risk assessment and opioid contract and scan them into the chart.
Stamps and templates
Use these in your computer to prompt more thorough charting. Do not use them as tick boxes. The “__” indicates information you must fill in.
Abdominal pain for __ days
Caused by __
Improved by __
Aggravated by __
Feels like __
Constipation __
Diarrhea __
Blood __
On examination temp __
ENT __
Chest is clear to inspection, percussion and auscultation __
Bowel sounds __
Rectal __
Assessment: __
Plan: __
(Left or right) Ankle injury __ days ago
Mechanism of injury __
On exam, range of motion __
Swelling __
Ligaments __
Assessment: __
Plan: rest, ice, elevate, tensor or plastic boot cast (delegate to fracture clinic), physio, Advil, 2 every four hours, call in one week if no better.
Blood pressure
Subjective: Feels __ (eg. No chest pain or shortness of breath no swelling of ankles).
Objective: BP is __
Cardiovascular system heart sounds S1 and S2 are normal, no murmurs. Chest is clear to inspection, percussion and auscultation.
Assessment: __
Plan: See prescription plus diet, low salt and exercise.
Cholesterol level is __
Subjective: Feeling __
Objective: ENT normal.
Cardiovascular system: Heart sounds normal no murmurs, no congestive heart failure, no jugular venous distension, pulse, normal sinus rhythm. Chest is clear to inspection, percussion and auscultation.
BP __
Pulse __
Assessment: __
Plan: __
Depression for __ (period of time)
Fatigue __
Sleep __
Crying __
Blaming yourself or feeling worthless __
Lack of concentration __
Lack of joy __
Weight change __
Faster or slower than others __
Suicidal thoughts __
Rx : exercise, omega 3 foods, sleep Bipolar 1.
Series of questions: Has there ever been a period of time when you were not your usual self and…
…you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
…you were so irritable that you shouted at people or started fights or arguments?
…you felt much more self-confident than usual?
…you got much less sleep than usual and found that you didn’t really miss it?
…you were more talkative or spoke much faster than usual?
…thoughts raced through your head or you couldn’t slow your mind down?
…you were so easily distracted by things around you that you had trouble concentrating or staying on track?
…you had more energy than usual?
…you were much more active or did many more things than usual?
…you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
…you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
…spending money got you or your family in trouble?
Diabetes
Latest HbA1C __
Latest micro albumin/creatinine ratio __
Latest creatinine __
Latest cholesterol __
Latest TG __
Latest LDL __
Latest HDL __
Latest ophthalmology consult __
Latest optometry consult __
Latest podiatry consult __
Subjective: Diet __, exercise __, smoking __
Objective: BP __, CVS __, RS__, Fundi __, Feet __
Assessment: __
Plan: __
Hip pain for __ (period of time)
Due to __
On exam __
ROM __
Wasting __
Neuro __
Assessment: __
Plan: Physio, __
Knee pain for __ (period of time)
Cause of problem __
Range of motion __
Ligaments __
Redness __
Temp __
Assessment: __
Plan: __
Complete Physical Exam: Male (note, for females substitute breasts and pelvic exam and pap smear for prostate tests. If over 50 do bone density and mammogram every three years).
Problem __
Functional enquiry: Head and neck __; ears, nose and throat __; respiratory system __; endocrine system __; cardiovascular system __; digestive system __; genitourinary system __; musculoskeletal system __; central nervous system __
General appearance: Wt __ Ht __ BMI __
Ears nose throat __
Skin and mucosa __
Cardiovascular system: BP __; pulse __; heart sounds __; JVP __; peripheral pulses __
Respiratory system: Abdo __
Central nervous system: Pupils and fundi __; cranial nerves __; tone __;
power __; coordination __; sensation __
Testes __
Prostate __
Assessment: __
Plan: __
Shoulder pain for __ (period of time)
Caused by __
Range of motion __
Crepitus __
Wasting __
Neurological exam __
Assessment: __
Plan: Physio, ice, heat.
Skin lesion for __ days
Objective: Size __; shape __; colour __; itchy __; where on body __; what has been tried __
Assesment: __
Plan: __
Cold for __ days
Sore throat __
Cough __
Earache __
Sputum __
On examination: Neck supple; temp __; ENT __; nodes __; chest is clear to inspection, percussion and auscultation.
Assessment: __
Plan: __
Urinary tract infection
Frequency and dysuria for __ days.
Subjective: Temperature __; back pain __; abdomen __; bowel sounds __
Assessment: __
Plan: Drink cranberry juice, lab, Rx
One final note: Always use Choosing Wisely and Canadian guidelines. Under “assessment” put how the patient is doing. For example: blood pressure is well controlled.
What do you think? Comment at Canadian Healthcare Network or email him.
Dr. John Crosby is a family physician in Cambridge, Ontario and assistant professor of medicine at University of Toronto and family medicine at McMaster and Queens. You can also email him for a free e-book, at DrJohnCrosby@rogers.com (also available in audio format) on Avoiding Physician Burnout.
From 2Ascribe: You can also check out the comments on this post for an interesting, sometimes lively and informative discussion.
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