The Art of the Chart: Documenting the Timeline


The timeline of a patient’s symptoms is often crucial in making a correct diagnosis. Similarly, the timeline of our own clinical decisions is necessary to document and review when following a patient through their treatment.

In the old paper charts, particularly when they were handwritten, office notes, phone calls, refills and many other things were displayed in the order they happened (usually reverse chronological order). This made following the treatment of a case effortless, for example:

3/1 OFFICE VISIT: ?UTI (where ciprofloxacin was prescribed and culture sent off)

3/3 Clinical note that the culture came back, bacteria resistant and treatment changed to sulfonamide.

3/5 Phone call: Patient developed a rash, quick handwritten addition on left side of chart folder, sulfa allergy. New prescription for nitrofurantoin.

3/8 Phone call: Now has yeast infection, prescribed fluconazole.

Each of these notes took virtually no time to create and you could see them all in one glance.

In one of the EMRs I work with (hi, Greenway, it’s me again), when the culture comes back and I need to change the antibiotic, I open the patient’s chart, go to the medication section and hit the + sign. The system then asks me which existing “encounter” I want to use for my new prescription. Excuse me, I am sending in a new prescription right now, doesn’t the system know what day it is? How could I today send in a new prescription dated yesterday?? So I have to create a new encounter, choosing “medication encounter” as the type and then I’m good to go. Sort of. That type of encounter doesn’t display when I later look at my office notes, because it isn’t classified as an office note.

When the patient later calls to report the rash, that telephone call comes to me as a “task” (oh, how I despise that demeaning word…), which will also not enter the timeline of office notes. I can create a medication encounter when I change the antibiotic again, just like with the first medication change. I can then use the same encounter to document the allergy. But if I want my actions to display in any kind of timeline, I have to use the encounter type “chart update”, which will enter the encounter list.

This is all very fussy and, frankly, reminds me of working with the earliest versions of DOS, which many of my readers are too young to even have encountered.

The time it takes to document the simple clinical scenario I described above in my current EMR – and to review the next time I see my patient – compared to when we did it on paper is 5-10 times longer.

Some progress, huh.

I wish the EMR would know that when I add a medication, I am doing it today and not yesterday.

I wish that it would know that it is a medication encounter when I am adding a medication.

I wish the EMR would display the story as simply as the old paper chart. I’m sure it’s possible. Computers can do amazing things. But of course, it’s a question of whom the holy grail actually serves.

Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.

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