Hi everyone,
The EMR has transformed the way we show test results, though not in a good way. In the days of paper and pen, we strove for efficiency:
We used fishbone diagrams and common abbreviations, sticking to the essentials. We lacked the time, patience, and hand strength to include more.
If we don’t take control, the EMR will drown us in oceans of data. I’m sure I’m not the only reader who scrolls quickly past the results section, which raises a question: why document results at all? Why not just confirm we’ve reviewed the results and move on? If someone wants to see the data themselves, they know where to look.
That said, I do think we should document important findings, because doing so highlights key issues and helps explain our clinical reasoning. But we should be judicious about the results we list, so consider these principles:
- Follow an order: Predictability promotes efficiency and completeness and helps readers anticipate what’s coming. Here’s a common and reasonable order: bloodwork, U/A, micro, EKG, imaging.
- Don’t repeat: Restrict yourself to new findings. Studies done before admission go in the HPI since they’re not part of your work up (e.g., “an echo done at L&M showed an EF of 10%, prompting transfer to the YNHH CICU”). Delete old results, particularly imaging studies; otherwise it’s hard to tell what’s old and what’s new. The exception is when you’re emphasizing trends, like falling platelets or rising LFTs. If you must repeat results, include dates to prevent confusion.
- Highlight key findings: Use bold or red so abnormalities stand out.
- Summarize imaging: Imaging results, particularly CTs and MRIs, are long, so just include key findings. For example, for a CT PE study, document the main result (“saddle embolus”) and leave out the irrelevant parts (normal lung parenchyma, soft tissue, etc.).
- Distinguish what you say and what you write: Expectations change by setting, so check with your team. In the MICU, where so much is abnormal, it may be more efficient to read all the results rather than dwell over what to say and what to leave out. On the floor, it’s generally fine to restrict yourself to the key findings. As you gain experience, the team will trust your judgment, so you’ll be able to say the results were “normal” or “unchanged” without being asked to prove it. As with the history and physical, highlight both pertinent positives and negatives: for example, if a patient is bleeding, report the H/H, platelets, and coags, even if normal.
- Own your findings: If a patient has abnormal results, you’re responsible for following up. Be careful about unexpected findings, particularly those buried in the bodies of imaging reports. For example, if a lung nodule is found on a CT done for other reasons, you have to make sure it’s worked up, if not in the hospital, then afterwards. Best practice requires that you document telling patients and their outpatient clinicians about these findings so they know to follow up.
In summary, use the test results section of your presentations to highlight salient findings as you transition to the assessment section, which we’ll tackle next week.
Enjoy your Sunday, everyone!
Mark
PS On an unrelated note, a compassionate take on Simone Biles’ struggles at the Olympics: The Yips, the Twisties, the Waggles: Simone Biles Gets Them, and You Probably Do Too
MDS