Opinion | ‘Agree With Dog’ and Other Obscure Patient Chart Notes

I keep hoping that we are going to get to a place where we can use the medical record for what it really should be.

As we evolved away from paper charts, and smeary, inky, illegible doctors’ handwriting, the promise of an electronic medical record that really helps us take care of patients emerged — we’ve just never been strong enough to insist that it become what we need, what we really need.

Many years ago, when we used to roll around a rack of paper charts on floor rounds in the morning, the attending would write their brief note as an addendum on whatever long tomes we interns and residents had crafted.

I remember one particular instance from years ago, when I was rounding on a patient with one of my favorite attendings. This patient had already been seen by multiple subspecialists who had already suggested various interventions. My attending was trying to figure out why this particular patient was massively swollen, and he wrote with his bright blue fountain pen just a few immortal words:

“Maybe they’re just fat?”

It was probably not the most politically correct note in the world, but it clearly got across what he was thinking: all the obscure tests and specialized imaging that multiple specialty consults had ordered weren’t really going to add that much, and in his eyes, there was probably nothing to do except move forward with whatever treatments might help.

Another one of my favorite chart notes from days gone by was three words, the only three words, written on a single sheet of note paper in the chart: “Agree with dog.”

Only after flipping to the previous pages in the chart could we read about the patient’s complex psychosocial situation, which had complicated their medical care and left them devastatingly alone at home with little social contact, and the resident thought that suggesting bringing a pet into their lives could immeasurably improve their mental state and overall health.

The attending agreed. Agree with dog.

These days, our charts remain bloated with endless macros, templated exams, pre-written fast-tracked gobs of text that create more noise than provide actual clinically useful information.

Recently, after a devastating stroke, a patient of mine had been left bedbound at home and was getting 24-hour care from a terrific team of home care workers and skilled nurses.

As part of their discharge from the out-of-state hospital near their second home where they had been when the stroke occurred, the inpatient team had requested a consultation with a gastroenterologist to help manage this patient’s severe reflux and feeding tube needs.

No one from our institution was able to follow this patient due to their out-of-state location, but the family was ultimately able to find a local gastroenterologist who did video visits.

They sent me their consultation note, and unfortunately, it read like so many others.

There was, miraculously, a detailed history, as if the patient had told them everything that had happened to them, as well as their current symptoms.

There was a detailed review of symptoms listing multiple (mainly negative) fully fleshed-out organ system reviews, and a few positive ones relevant to this particular specialist’s field.

Next came the physical exam: “normocephalic, atraumatic.”

Wait, what?

“Lungs clear to auscultation bilaterally, heart regular, normal S1 S2, no murmurs, abdomen soft, non-tender, normal bowel sounds, no masses palpated, feeding tube site intact, no rebound or guarding, extremities with good distal pulses, no pitting edema, alert and oriented times three, normal judgment and insight, thought processes normal, no focal neurologic deficits.”

All of this from a video visit?

And all of this on a nonverbal patient who’s lying immobilized in bed with minimal movements and only responding to simple commands?

Wouldn’t it be better if we just spoke the truth?

I really wouldn’t mind, and I don’t think anyone would mind, if the note said something like, “I saw this patient in a video visit for these reasons, and they appeared comfortable in bed with multiple caregivers around them, their feeding tube site looked intact. I recommend they continue their proton pump inhibitor, and said we can advance their tube feeds as tolerated based on the inpatient nutritionist’s recommendations.”

The rest is all fluff.

Writing “normocephalic, atraumatic” in your notes to me implies that you did a phrenological reading of this person’s skull, and by the way there were also no signs of blunt force trauma.

Save this for pediatrics clinic, or the emergency room.

If there is something you write in your notes every time, and every time it is exactly the same, then it probably doesn’t need to be there.

Write down what matters.

The January 2021 billing and compliance guidelines eliminated the need for so much of the chart extravagance that we used to be forced to add. I have been hoping we would all have moved faster and farther away from documentation for the sake of documentation, and moved towards the truth.

The electronic medical record allows us to generate massive review of systems and physical exams and templated entire office visits with the click of a button.

But does this really help us take better care of our patients?

Many have talked about how the advent of artificial intelligence, and its movement into the doctor-patient interaction, should help us get closer to the truth.

I hope this is the case, that these things will do a good job of representing what actually happens in that interaction.

Maybe someday a really smart (and really secure) system will listen in, and maybe even watch us as we talk to our patients and examine them; and then will help generate an accurate record of what happened in the room and what our thought processes were about our medical decisions and plans for moving forward for each particular patient.

There certainly could be countless suspected and unknown potential pitfalls and built-in biases to these systems, the ease with which we will be able to say, “Write me a three-page fully fleshed out note documenting every review of systems and every organ system examined, and listing the differential diagnosis with references and putting down that I’ve explained every risk, benefit, and alternative to the patient and that they have chosen to proceed and I’ve answered all their questions fully to their complete and utter satisfaction.”

But perhaps enough is enough.

By letting administrative nonsense and bureaucracy come between doctors and their patients, we in the medical establishment allowed for this junk to get in the way of what a medical record is really for, and now I hope that as things continue to evolve, we stand up for the truth.

Everyone deserves the truth.