Charting

I stare at my blinking curser, long after my last patient has gone home. I can see the long line of cars on the highway from my office window, their red tail lights like a swarm of angry insects. Everyone is on their way home. Everyone but the midwives.

I have spent my day counseling, asking delicate questions, touching people as gently as I know how, joyfully listening to baby heartbeats or delivering unexpected news. And now I have to write it all down.

If you had asked me to describe to you what my life as a midwife would look like before my training, I doubt I would have told you that roughly half my time would be spent sitting at a computer, fighting technology, and clicking buttons in a charting system. So many buttons.

Some days I am able to keep up with my charting and right after the visit am able to put my thoughts to “paper” and can swiftly move on to the next person. This has become a distant notion from the days when I was still building my practice. Now, I routinely see 15, 17, 19 patients in an eight hour day, many with complex gynecologic issues. It has also been made all the more impossible by having a delightful, but extremely time consuming, midwifery student this quarter.

Having a green midwifery student this quarter has forced me to slow down my usual rapid-fire pace of reviewing histories, asking questions, and conducting full exams in the blink of an eye. It has also forced me to take a hard look at all the things I do, say, and write about my patients.

The medical record has long been a sacred document that not only allows us to write down our observations about the people we care for, but allows us to show our thinking process and engage in the applied science of nursing. Every nurse also knows the old adage that if it isn’t charted, it didn’t happen. Charting serves as a way to communicate to ourselves for the next time we see the patient and show progress, or lack thereof, in treating a health issue. It also allows us to communicate with each other about our plans and a person’s overall health. It is also extremely time consuming and tedious.

As a teenager I sat on a cold table, the paper beneath me crinkling with every movement. I think of all the words I have seen in other patients’ charts. Psychosomatic. Dramatic. Non-compliant. Argumentative. Drug-seeking. Many of these words lie in my own chart from over a decade ago. I saw neurologists, endocrinologists, internists, chiropractors, psychiatrists, acupuncturists, and finally a rheumatologist, before a diagnosis explaining the cause of my chronic pain finally came.

These words riddle the charts of women. These words undermine patients and their stories before they even walk in to see a new provider. It is easy to write, “patient refuses. Patient will not. Patient defensive.” This style of charting exposes the deep power imbalances and systemic sexism and racism that are rampant in healthcare.

The words we chose in our charting matters in how we think about the care we provide and the provider/patient relationship. I tap away of my keys madly while my midwifery student watches every word appear upon the screen. “Patient states…” appears. And slowly I hit the delete button. “Sharon says…” This simple act of writing down names in our charting rehumanizes the people we see day in and day out under a deeply dehumanizing healthcare system.

It is easy to lose track of this deeply human aspect of healthcare, tucked behind our computers, typing away on a screen. For this reason I refuse to do my charting in the room. This flies in the face of what every single administrator has told me since I have been in practice. It’s more efficient, they all say. Put your lab orders and tests in right there, as you talk! Type out the patient’s history as you chat.  I have so many buttons to push and i’s to dot and t’s to cross in order for my charting to meet both billing guidelines and nationally mandated “meaningful use” measures that I cannot safely and competently conduct a visit while doing all these things. In order for most of us to keep up with our busy schedules and run relatively on time in our day and not leave an hour (or more) of paperwork at the end of our day, many of us do chart in the room. But I think a certain part of the intimacy of providing health care disappears with their use in the room. 

As I teach a budding midwife all the aspects of midwifery, not just what happens inside an exam room, but outside of it, has me recommitted to infusing my charting with the feminist principles that I hold so dear. How hard is it really, to write down a name? To explain that a patient declines with informed consent? The patients we care for bare their souls to us, terrified of judgement, and we owe it to them to be respectful and kind in our retelling of their stories. 

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One Response to Charting

  1. Sharon Muza says:

    Thank you for being kind, gentle, caring and sensitive. It makes a world of difference that you *see* people as different individuals with feelings rather than the “IUD” or “STI” or as difficult or defensive. I always remember what Penny Simkin says, we may not always understand why people behave the way they do or make the decisions they make, but they always have good reason. Thank you for seeing people as people.

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