Everything We Say and Do

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”

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What I say and do

I inform my patients that I have reviewed their chart and that I am familiar with their diagnosis.

Why I do it

In the hospital setting, in particular, patients are concerned about communication between their various healthcare professionals. Many times, the patient’s primary-care provider works strictly in the outpatient setting, so the hospitalist is the person who assumes total care of the patient throughout hospitalization. This understandably creates anxiety for patients and families because they wonder if the hospitalist really knows their medical history. One way to alleviate this anxiety is to review your patients’ charts prior to speaking with them and to verbally let your patients know you are familiar with their diagnoses.

How I do it

Step 1: Before entering the room, I review my patient’s chart. If I am taking over the service from my colleague, I review all notes from the current hospitalization to ensure I understand everything that has happened. I also review tests, procedures, and radiographic studies. To gain a better understanding of my patient, I read the most recent discharge summary and outpatient clinic note. Likewise, if I am admitting a new patient to the hospital, before entering the room to do the history and physical examination, I review recent hospitalizations, clinic notes, and emergency department visits.

I also like to review the chart to see if I have taken care of the patient before. Patients often remember me even though I may not remember them, so reviewing my prior notes may be helpful. Thankfully, my electronic health record (EHR) has a search function where I can enter my name or any other keyword and it searches for patient records based on this keyword.

Step 2: Even though reading the chart and being informed about my patient is important, it is only the first step. The next step is to let my patient and family know that I have read the chart and that I am up-to-date on my patient’s diagnosis. I feel it is very important for me to verbalize that I have read the chart because without doing this, my patients never really know that I took the time prior to entering the room to learn about them.

I might say:

• “I was reviewing your chart before I came in, and I saw that your daughter brought you to the hospital for chest pain.”
• “I read your chart and saw that you have been to the emergency room twice in the last week.”
• “I read your primary-care doctor’s note, and I saw that she recently treated you for pneumonia.”
• “I read your chart, and I wanted to confirm a few things I read to ensure we are on the same page.”

There are many different ways you can phrase this, but the important point is to make sure your patients know you read the chart by specifically referencing something you learned. This helps your patients feel more confident that you know their medical history.

I know some of the doctors reading this column see patients in the outpatient setting. One way to help yourself remember pertinent facts about a patient’s medical history is to include these facts in a specific place in your clinic note. That way, prior to seeing the patient, you can always review your last note and know the important information about your patient’s medical history will always be in the same place in each note. Another tip is to use your EHR’s note function. My EHR has “sticky notes,” and they provide a place for the PCP to store information about the patient without it becoming part of the permanent medical record.

These notes allow the PCP to record important events that happen between one clinic visit and the next. Thus, when the patient returns to the clinic, the PCP opens the chart, reviews the sticky note, and enters the exam room prepared to discuss significant events in the patient’s recent medical history.

In the end, it does not matter which technique you use. It simply matters that you take time to review your patient’s chart prior to entering the room and that you verbalize what you have learned. In patients, this inspires confidence and trust and helps alleviate concerns that the physician does not know important information in their medical history.