The Traditional (Paper) Hospital Record

The nature of men is always the same; it is their habits that separate them.

— Confucius: Analects, 500 BC

Habits, good and bad, are part of human nature. For doctors who practice medicine, knowing your patients through and through¹ and putting them first, always,² is a good habit. Conversely, a bad habit always serves the doctor first and might not serve the patient at all; in some cases, it actually harms the patient. This editorial focuses on selected examples of bad habits that I have found repeatedly in traditional (paper) hospital records.^*

The Doctor's Order Sheet

On the doctor's order sheet, I almost invariably see “Vitals Routine” or, occasionally, “Vital Signs Routine.” Contrary to what most house officers and many practitioners believe, vitals and vital signs are not the same. They have totally different meanings and should never be used interchangeably. Vitals refers to vital organs (such as the heart, liver, lungs, and brain). Vital signs refers to the signs of life: pulse rate, respiratory rate, body temperature, and blood pressure. Despite their differences, both terms trigger an automatic mindless response from the nurses, who then routinely measure the patient's vital signs 3 to 6 times a day. And they do so even when the patient is asymptomatic, hemodynamically stable, afebrile, and ready for discharge.

Think about it. Do all hospitalized patients—especially those who do not have life-threatening illnesses and who are not in special care units—really need to have their vital signs measured at least 3 times a day? I think not. And is it always in patients' best interests to awaken them from a restful sleep to obtain such measurements? Definitely not.

What do you suppose might happen if a doctor were to write an order for no measurement of the vital signs or for measurement of them once a day only? To answer that question, I wrote such orders in a private hospital and in a city-county hospital. In both places, the nurses became upset, claiming that their nursing policy required them to record the vital signs of every patient at least 3 to 4 times daily, regardless of the patient's condition. It seems, therefore, that many nurses, like many doctors, just follow the herd.

Another mindless order often appears when the patient is febrile: “bld cx ×2.” This order (for 2 blood cultures) is bad, not only because it is abbreviated (providing room for confusion), but because it leaves the nurse responsible for deciding how much blood to draw and when to draw it. Given such an order, nurses typically do 1 of 2 things: they remove a large sample of blood and apportion it into 4 culture tubes (2 sets), or they draw about 10 cc of blood, place equal parts into 2 tubes, and repeat that procedure 30 minutes later.

To eliminate confusion, ensure the most reliable results, and place responsibility where it belongs, the doctor should write out “blood culture,” cite the exact time that each sample is to be obtained, and specify that 20 cc of blood is required for each culture (10 cc into the aerobic tube and 10 cc into the anaerobic tube).

Next is “Sputum for AFB ×3.” This order, written for patients suspected of having pulmonary tuberculosis, requests stains of 3 separate sputum samples for acid-fast bacilli. It is a faulty order because the standard “3” proves in many cases to be an excessive number, while in other cases it isn't enough (3 negative samples do not always rule out tuberculosis). So a more sensible and economic approach is to order the staining of 1 sample at a time until the test becomes positive or the clinical suspicion of tuberculosis ends.

Comment: The care that any hospitalized patient gets—be it good or otherwise—boils down to 1) what the doctor orders, 2) how the orders are interpreted, and 3) when and how they are implemented. Tailoring the orders to the specific patient can save a lot of time, effort, and money. Therefore, we serve our patients best when we put our thoughts in order before we order.³

The Physical Examination Page

The physical examination page is fertile ground for bad habits. Take, for example, “A&O ×3”—a frequently used shortcut for alert and oriented to time, place, and person. I have found that most house officers consider “alert” to mean fully oriented. Not true. Alert means watchful and ready, on guard. In that sense, a person can be alert but not fully oriented or fully oriented but not alert. Despite the fact that some patients know who they are but do not know where they are or possibly what time it is, I have never seen “A&O ×2” or “A&O ×1.” At any rate, I suggest that we delete the A&O ×3 jargon and substitute a spelled-out, precise description.

Another abbreviation of note is PERRLA (pupils equal, round, and react to light and accommodation). According to Levin,⁴ this time-honored recording is incorrect, inexact, and incomplete. I agree. Moreover, when I see that abbreviation in a current record, I usually ask the recorder, “Did you actually test the pupils for accommodation?” The answer usually is, “No.” Similarly, “cranial nerves intact” is a common recording, but most of the time cranial nerves I, II, and VIII have not been tested.

Next are “Pelvic Deferred” and “Rectal Deferred.” In most instances, no explanation is given for why these examinations are deferred. I suspect that the doctor considers them to be unnecessary, unimportant, or simply inconvenient. Whatever the reason, failure to perform these examinations can have serious consequences, the worst being failure to detect an asymptomatic but still curable cancer of the rectum or cervix. As Joseph Sapira emphasized in his magnificent text on bedside diagnosis: “If you don't put your finger in it, you'll put your foot in it.”⁵

Finally, “Normocephalic, atraumatic.” This mindless, herd-mentality recording is a feeble way of saying that the patient's head is normal in size and shape and that it has no gaping wound or other sign of injury. Since most people have a normal-appearing head without signs of injury, it isn't necessary to make a specific point of this in writing. After all, we never write, “ears normal in size and shape, atraumatic,” or “legs normal in size and shape, atraumatic.”

Comment: Why is the physical examination the source of so many bad habits? The answer has several parts. With the rise of high-tech medicine, high-touch (bedside) medicine has fallen, and emphasis on the physical examination has steadily waned. As a result, doctors' clinical skills have progressively deteriorated.⁶ In addition, the course in physical diagnosis at most American medical schools has become woefully inadequate. Many of them consist primarily of lectures, and if any hands-on teaching occurs, house officers commonly do it.

And why do so many doctors continue to make false recordings of the physical examination? As medical students, they see interns, residents, and some faculty members doing the same thing. Because herd mentality is the rule in medical school, students mindlessly embrace the habit and never let it go, even though it is dishonest and potentially harmful to the patient.

The Progress Notes

Many consultants from various disciplines routinely end their reports with, “Thank you for allowing me to participate in the care of this most interesting patient.” What is the difference between an uninteresting patient, an interesting patient, and a most interesting patient?⁷ The answer, like beauty, lies in the eyes of the beholder. In my eyes, all patients are interesting, but not all doctors are interested.⁸ A simple “Thank you” or “Thank you for this consultation” would be sufficient and devoid of insincerity and cliché.

Finally, “The patient is ‘satting’ at 88%.” This expression of the patient's oxygen saturation level crops up frequently, not only in hospital records, but also in Morning Report, teaching rounds, and doctors' lounges. Patients can sit or be sitting, but they can't sat or be satting. To sat is not a verb form. It's a neologism—arguably the most popular neologism in medicine today. House officers are particularly fond of it, uniformly include it in case presentations, and consider it the 5th vital sign.⁹ Unless teaching faculties consistently prohibit its use by all trainees, “satting” will continue to saturate the medical environment.

Comment: Effective communication with patients and colleagues is a sine qua non of the compleat physician. And because we as doctors are held to the highest of standards, all of us should be circumspect in what we say and how we say it.

Conclusion

Old habits die hard. For that reason, I shouldn't expect this editorial to make a dent in the bad habits it spotlights. But as Alexander Pope said almost 3 centuries ago, “Hope springs eternal in the human breast.” So if enough of you share my views and come up with grievances of your own as illustrations, together we can make that dent. Let's get started!