Skip to main content

Six Awkward Concerns in My Not-Yet-Opened Notes

Note: This baby is not a veteran, nor is this the VA Medical Record system. 
The VA has just taken a big bold leap forward: access to progress notes has been added to MyHealtheVet.

I'm impressed and think this is great. I also however can't help thinking of several awkward issues, related mainly to geriatrics, that crop up regularly in my own progress notes.

So I've written a blog post on this issue, and it's live today on The Health Care Blog.

In the post, I describe the following six awkward topics that might make patients (or caregivers) upset, if they were to read about my concerns in the progress notes. Here's my quick list:
  • Possible cognitive impairment
  • Possible elder mistreatment (a subject just recently raised on this very blog)
  • Possible abuse or diversion of prescription drugs
  • Possible substance abuse, especially alcohol
  • Concerns about ability to manage safely at home or while driving
  • Concerns voiced by family or caregivers

As we know, these are issues of importance to the health of older adults. Unfortunately, to date they've generally gone under-recognized and under-addressed by clinicians overall.

Any thoughts on how we should navigate these issues in an age of OpenNotes?

And are there other awkward topics that you find yourself wondering how you'll document?

by: Leslie Kernisan, MD MPH

Comments

Maggie said…
I suppose it's obvious why a caregiver might be upset if your Open Note mentions possible elder mistreatment.

But the rest? If you're my doctor, I want you to discuss your concerns with me. If you're wondering about cognitive impairment, it's very likely that I already worry about that. Writing it in your notes without telling me seems ... Well, you'd have to explain your rationale.

Concerns about my ability to drive? In my younger days, driving was almost as important as eating. But if you're concerned about my driving, who would you tell, if not me?
Jill said…
It’s all about transparency in communication. Someone (forgive me for not remembering who) recently said, “No on cares more about my medical record than I do.”

How much have we learned about the power of saying “I’m sorry,” when mistakes are made? It reduces misunderstanding, builds trust, and decreases the number of lawsuits resulting from medical error.

Now is the time to teach the next generation of medical caregivers of all disciplines that the medical record truly does belong to the patient and teach them how to give the person who is most concerned the true information: the good, the bad and the ugly. Sensitivity is not secrecy – it is learning to say the whole truth with tact and with a compassionate understanding of how the knowledge will be applied.
leslie kernisan said…
Thanks for these comments!

Popular posts from this blog

Dying without Dialysis

There is a terrific article in this weeks Journal of Pain and Symptom Management by Fliss Murtagh of King's College in London about the epidemiology of symptoms for patients with advanced renal failure who die without dialysis.  This study is important because while we know that patients with advanced renal failure have a limited life expectancy and the average age of initiation of hemodialysis is increasing, we know little about the alternatives to hemodialysis.  Specifically, we know nothing about symptoms affecting quality of life among patients who elect not to start dialysis (so called "conservative management" - is this the best label?).  This article provides a terrific counterpoint to the article in last years NEJM showing that nursing home residents who initiated hemodialysis tended to die and decline in function (see GeriPal write up here). 

The study authors followed patients with the most advanced form of chronic kidney disease (the new name for renal failu…

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …

Survival from severe sepsis: The infection is cured but all is not well

Severe sepsis is a syndrome marked by a severe infection that results in the failure of at least one major organ system: For example, pneumonia complicated by kidney failure. It is the most common non-cardiac cause of critical illness and is associated with a high mortality rate.

But what happens to those who survive their hospitalization for severe sepsis? An important study published in JAMA from Iwashyna and colleagues provides answers and tells us all is not well. When the patient leaves the hospital, the infection may be cured, but the patient and family will need to contend with a host of major new functional and cognitive deficits.

Iwashyna examined disability and cognitive outcomes among 516 survivors of severe sepsis. These subjects were Medicare enrollees who were participants in the Health and Retirement Study. The average age of patients was 77 years.

When interviewed after discharge, most survivors were left with major new deficits in their ability to live independently. …