A New Medical Service

A long with the demise of many of the outlandish ideas of the late 1960s that so entranced some of our best thinkers, concern for the state of the medical record has died a peaceful death. In our hospital the problem-oriented record has ceased to be a problem since reduced to a single page of yellow paper somewhere near the top of the chart, which within two days of the patient’s admission, resembles any exposed surface in New York City. Those members of the faculty that talk about patient records again do so with the reticence that once was reserved for the discussion of one’s sex life. Nevertheless, the patient’s chart will not go away. That is unless you want it.

At most of the hospitals I have familiarity with, the Record Department seems to exist for the sole purpose of losing the chart. An endless line of patients seems to be entering our hospitals from the outpatient clinic without outpatient records. Or, the patient is readmitted but his record of previous hospitalization is not. Why we can find our patients but not their charts is a great unanswered question.

Two solutions come to mind. The first is to close the record room and throw the charts away as soon as they reach a certain bulk. (Of course they may be lost before reaching critical weight, but that would be all to the good.)

The second solution has the virtue (or drawback) of optimism. It attempts to regularly review the patient’s chart. Close the record room and give the patient’s chart to the patient. He can lose it for less money than can the record room. Since he can regularly find his way back and forth from the hospital and/or outpatient clinic he might do so with his chart.

Having solved the problem of the lost chart, we must now face the problem of what to do with it when we have it. One of the problems of decreeing that everybody who works in the hospital is a “professional” is that everybody wants to write in the chart. I have no doubt that before long the elevator operators will be writing regular notes in every chart. As a result of this institutional prolixity the average medical chart soon reaches Proustian dimensions. Consequently, nobody reads the chart.

There is no doubt that useful information occasionally finds its way into the chart. Gresham’s law operates here as in economics. Bad information drives out good — or at least completely obscures it. There needs to be some way that useful information can be extracted from the compacted effluvia that constitutes a typical medical chart.

The solution, in my view, to this problem is to form a new service — the Chart Reading Service. When confronted by a large and complicated medical record, the attending physician can consult this service. The physician (from the Chart Reading Service) who answers this consultation will carefully read the chart and write a brief note outlining the pertinent information contained in it. This note will never exceed 200 words.

In addition, new chart racks can be designed that automatically weigh the chart and send in a consultation to the Chart Reading Service when the weight of the chart, exclusive of the chart holder, exceeds one pound.

I can envision the proliferation of this service to all hospitals and even to doctors’ offices. Fellowships in Chart Reading soon will be offered. The American Board of Chart Reading will be established and give biannual certifying examinations. In due time, a committee of program directors of Chart Reading Services will convene a meeting that will establish a uniform acceptance date for applicants for fellowships in Chart Reading.

Finally, Medicare, Medicaid, and other third party payers will establish a ‘‘reasonable’’ charge for this service. The payment for Chart Reading will of course require a note in the chart (this allows for an infinity of chart reading opportunities) signed or countersigned by an Attending Physician. The fee will be based on the weight of the chart read, about $150/pound seems right. Follow-up visits will be less.

When in doubt, expand.

Originally Published:

Kurtzman NA (ed): A new medical service. Sem Nephrol 1:209, 1981.

Electronic records may help some. While you can lead a doctor to a computer, you can’t make him read. Some medical specialties are doable without any reading skills.

NK Dec 2007