Some notes on notes

This is going to be a preachy one, I’m afraid, and I hate getting preachy unless it’s about something close to my heart (such as all the things Tim Burton’s remake of Planet of the Apes got wrong, or why The Force Awakens being basically a remake of A New Hope is no bad thing for Star Wars).

However, if you’re not in the mood to be preached at then go and have a cup of tea and read a different one (my previous blog has a funny anecdote in it, try that one).

Everyone braced? Good.

…and hilarity ensued

Now, it has been said I can write an amusing sentence or two when the mood takes me; occasionally, it has even been said by other people. Every so often, someone says to me: “Your blogs are so funny – your clinical notes must be hilarious!”

Well, no. There’s a clue in the name. My notes are very boring, brief (but detailed) and to the point, and that’s because they have a job to do. The clinical notes are the vet’s advocate in his absence and their job is to, very quickly, bring another clinician up to speed on the case so far, and, if necessary, your future plan for dealing with the case.

If I am unexpectedly absent, or the patient comes in out of hours, or decides to move to another practice, those notes should make the case as clear as possible, as briefly as possible – vets generally don’t have time to read pages of notes.

How to suck eggs

Sitting here, typing this while staring forlornly at my empty cup of coffee, this seems so self-evident and obvious that I’m concerned this may be my dullest blog ever, but I can’t tell you the number of times I’ve been embarrassed, frustrated, confused or angered by clinical notes (actually, I can tell you – a lot).

I know getting clinical notes right can be difficult, especially when you’re behind schedule and 10 people are waiting, and you want to get home. I certainly haven’t got it right every time, but I have at least tried because it’s important.

Getting clinical notes wrong not only wastes time, it can be detrimental to your patient’s welfare and it can get you in trouble with the RCVS.

What follows are some of what I consider to be cardinal sins with clinical notes, all of which I have encountered during my career:

1. Inappropriate comments

Clinical notes are not the place to make chatty bon mots about your patient or your client. My rule of thumb is never to write anything in a clinical note that I wouldn’t want to have read back to me by a stern-faced barrister.

The days of “amusing” acronyms like NFN (normal for Norfolk) or DSTO (dog smarter than owner) are thankfully long behind us, but I’ve had the dubious pleasure of trying to stand between my screen and the owner to conceal the notes “phwoar, never mind the cat, I wouldn’t mind giving him a clinical exam!”, written by a colleague about the owner’s husband. Awkward.

Insulting comments about the client, which I’ve also encountered frequently, are even worse and potentially libellous to boot. Please don’t. You’ll regret it, I promise.

2. I know I said be brief…

…but I would appreciate you actually writing something. Trying to pretend you have some idea what you’re talking about in a postoperative check, when you don’t even know what the bloody op was because nobody has written any notes at all, is not a fun experience.

I have spent several consults desperately hoping the client will let slip exactly where the surgical wound is that I’m supposed to be checking before it becomes clear that I haven’t the first idea what, if anything, has been removed from their pet, nor where it was removed from.

Attempting to work out exactly what medical condition the animal has from the drugs and doses prescribed may be an interesting mental exercise, but it’s also frustrating and embarrassing when you’re doing it in front of a client. It’s tough enough when you’ve been at a practice a long time, and so you may have at least some idea what has gone on, but it’s downright infuriating when you’re a locum and already at a disadvantage with the client.

I have taken the zero tolerance policy here of explaining to the client “I’m afraid my colleague hasn’t written any notes”, which never looks good for anyone, but at least it’s honest. Write some notes. Please. Just don’t tell me how sexy/angry/weird-looking the client is.

3. Medical language is there for a reason

Yes, originally medical terminology was designed to make doctors sound cleverer than patients, but it has evolved beyond that. The medical terms we use are descriptive, precise, reproducible and useful.

“Acute onset watery diarrhoea with increased urgency, tenesmus and mild haematochezia” tells me a lot. “Nasty diarrhoea” does not. What is nasty? The appearance? The smell? The dog? The grammar? How am I supposed to know if this has got better, or worse? What’s worse than nasty? “Really nasty”? If this dog gets diarrhoea again, how am I supposed to know if it’s the same as last time? Does that imply there is such a thing as “nice diarrhoea”?

Yes, I know I could talk to the client, and I will, but what if it’s someone looking after the animal, or it has changed owners, or the owner is (thankfully, like most normal human beings) not terribly good at describing the quality of their dog’s diarrhoea?

Similarly, “very good” is not a suitable assessment of a patient during a check-up, nor is “bad ear” a useful description of otitis externa (or aural haematoma, or peripheral vasculitis, or ringworm, or any of the hundred different things these notes could be referring to).

4. Actively misleading notes

I know we don’t generally try to fool each other – these are genuine mistakes that are perhaps more forgiveable than the previous note issues I’ve discussed, but they can lead to the biggest catastrophes.

We’ve all been guilty (okay, okay, I have) of writing “left” when I meant “right” – it’s amazing how quickly which side of an animal I have just looked at slips out of my head at soon as the consult door closes.

This is a very common mistake we’re generally alert to, but is always worth double-checking. If I have genuinely forgotten, or I’m not sure, then I don’t feel any shame in adding a qualifying “I think – please check next time” – at least it puts the next vet on alert.

However, I have occasionally encountered notes that actively lead me in the wrong clinical direction, to the detriment of the patient’s welfare – for example, I once sedated and attempted to remove a pin from a cat’s leg, only to find it already removed.

My colleague, who had written “pin left in place” on the notes after the previous x-ray, had apparently decided to remove the pin at the last minute, but hadn’t updated the notes or informed the owner. A small mistake, which led to an unnecessary anaesthetic.

Clinical notes. Let’s keep ‘em that way.