Chart personalities: Reminiscing about the tangible world of paper charts

I am a relatively early adopter of new technology, so it's amusing to write this blog reminiscing about my low-tech past.In 2001, Alberta started incentivizing doctors to digitize. Personally, I have not been on a paper medical chart for almost 15 years. Let's be clear, I believe EMRs have revolutionized our record keeping, and would never go back to paper charts. Having said this, the digital realm has lost something tangible, as paper seemed to tell a story that bits and bytes do not.For anyone reading this who has never actually written on a paper chart, may this not come across as the uncovering of the Dead Sea Scrolls or some archaic relic of our medical past. For those who've spent their careers with them, we know paper charts were unique. Paper charts had a personality. Let me explain . . . When I first moved to Calgary, I worked at an extremely busy family medical clinic. Half the front of the clinic was a veritable wall of medical charts on a shelving system that moved by turning a large mechanical crank. The charts were filed in alphabetical order, floor to ceiling, and this wall was IMPRESSIVE. We had at least two personnel whose job it was to compile all the charts each clinic day for the docs. They would essentially be running back and forth pulling charts if there were telephone calls, lab results that needed attention, or any additional fit-in patients. They spent the rest of their time doing all the chart filing that took place throughout a busy day. Just looking at that forest of charts gave you a sense of the massive scope of this clinic—a productive group of MDs managing the health concerns of a LOT of patients. These days, a big clinic EMR can all be stored on a single hard drive in a small broom closet. What a difference! Yes, we have more computing power on our cell phones than Apollo 13 did on their lunar mission. And whether using digital or old-school paper charts, clinics themselves still have the same old problems (e.g., toilet issues) as the high-tech space program today. Sorry, Artemis, just had to get in that juvenile potty humour.Voluminous charts Thick chart syndrome: In the olden days of paper charts, when you had difficulty picking up a chart due to its weight, you knew this was a frequent flyer patient with a long list of problems. The thicker the chart, the more likely this was to be true. At the beginning of a clinic day, one just needed to look at the pile of charts for the day to see how many thick charts would be sticking out like PVCs on an EKG tracing. Seeing too many of these might bring on a cold sweat and some nausea. There were some charts so distinctly voluminous that you didn’t even need to look at your day sheet to know who was coming in. Hopefully, your pile for the day only had a few of these charts, and you could breathe easy. Call it “thick chart syndrome,” where there was a linear correlation with chart size and number of chronic medical conditions.Volume II (and/or III)Chart obesity: Even worse than above, the too-thick chart morphed into a new and somewhat stealth chart: Volume II—or even Volume III in rare cases of chart obesity. Seeing Volume II or III on a chart represented not even a gold or platinum-tier frequent flyer; this was an elite flyer who could likely sit in the copilot’s seat and, with the pilot lulled to sleep by their endless chatter, land the plane on their own without incident. If they didn’t know every staff member in the clinic by name, every staff member certainly knew them, and not always in a good way. Funny how everyone at the front desk was SOOO busy when these patients checked in for their visits. Stained, strained and worn outFatigue: Seeing a worn-out chart with ketchup stains or a coffee mug ring on it generally meant a chart had sat on somebody's desk during lunch hour or was perhaps taken home to have notes completed. The fact that these worn-out chart notes could not be finished during the visit or usual clinic hours meant that this was a patient whose notes were complicated and needed more time to write out, whether this be for medical-legal reasons or to capture the essence of challenging medical issues. The frayed chart generally meant that something was not straightforward at all, and the MD author was struggling in one way or another. At times, a worn-out chart was a subtle sign of a patient deemed “difficult” requiring delicately worded chart notes. Seeing redRed flags: Seeing red ink on a chart was rarely a good sign. This could either mean that special attention was needed in setting up appointments, or this was a flag regarding patient behaviour: “ALERT! ABUSIVE PATIENT.” If a patient saw a red ink “warning” on their chart, this could be an interesting adventure. As such, red ink was usually inserted in discreet places on the chart. Alternatively, some clinic placed it prominently so patients would see exactly what was written in hopes that this might alter their behaviour. Today, there are a number of ways of prompting staff with pop-up notifications which remind them of a wide variety of issues relating to patients. The patients never actually see these. Pristine documentsThe skinny chart: In the past, seeing a crisp, new manila folder either meant this was a new patient to the clinic or that this person was healthy and taking good care of themselves. There is nothing more satisfying than opening a chart and seeing one page of visit entries, a limited number of lab tests (all normal), no diagnostic imaging, no past medical history, no past surgical history, no medications, no allergies. Of course, this could have meant the physicians were lazy and not capturing this data, or this was indeed a very healthy patient with literally no medical baggage. A clean slate. Generally speaking, the skinny chart was a thing of beauty. Light to the touch, easy to read, and a potentially quick and straightforward visit. We are all human; it is hard not to love the simplistic beauty of the pristine chart, a wonder to behold.And the handwriting!Once immersed in the chart, we were in a world of wonder, reading the handwritten scrawls of a multitude of physicians. The writing could be immaculate or fully illegible—pages of notes or cryptic abbreviations. Looking at my own handwriting, I could usually surmise how my day had been going when the notes were inputted. On a “good visit,” the penmanship was unhurried, the notes written with a light touch, and perhaps a bit of personality and wit. A “bad visit,” the handwriting appeared in a bolder font, cursed with a lot of quotations and exclamation marks. The heavier the hand, the worse the visit had likely been.For whatever reason, I was quite good at deciphering my colleagues’ notes, and I was commonly asked by staff to try to sort out a particular word or sentence. It was rare for me not to be able to figure it out, no matter how indecipherable the scrawl was. This was a fun aspect of handwritten charts. The handwritten note illustrated the flavour and personality of the physician who had written it. I didn't even need to see who had signed off; the note itself was the signature.I do recall a few physicians who had impeccable penmanship—notes that read almost as beautifully as Prakriti Malla (google her). I also recall other physicians whose notes were so brief that they were unusable. I recall a chart with documentation of an annual exam being abbreviated to a one-word entry: “CPX.” These were simpler times, when a patient/physician relationship was everything, and the contextual details were stored in the physician's head and not necessarily captured on the chart. This would not pass the sniff test today.We have lost this personal touch to a great degree with digital notes, particularly with the use of templates and macros. These provide excellent and comprehensive documentation but with them, the personality and the unique style of the individual physician have disappeared. As patients come in all different shapes and sizes, so did the paper chart. They were distinct and existed in a time which feels so ancient to me now. They allowed us to express ourselves not only in written word, but in style. Our writing offered customized fonts and formatting unique to each physician’s penmanship. These have become irrelevant on the homogenized digital EMR notes today.Medical charts today are clear and legible in comparison to those of the past. EMRs have come a long way in a very short time. They are powerful tools that have revolutionized our record keeping. With AI scribing systems exploding on the scene, “charting” feels like it is progressively changing every few months. No more writer’s cramp. Probably even less carpal tunnel or repetitive strain on keyboards. Verbal diarrhea may be the primary diagnosis of the next generation of MDs.Would I go back to paper charts? NO!Do I miss them? Just a bit? Yes, sort of. To all the paper charts out there: Still in active use, dusty on shelves, in storage facilities, waiting to be digitized or shredded . . . may we never forget you existed.Dr. Ted Jablonski is a performing artist and writer who has retired his family practice to focus on sexual medicine and transgender health in Southern Alberta, all while keeping his feet firmly planted in the front-line trenches of acute primary care.

Chart personalities: Reminiscing about the tangible world of paper charts

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