OPEN NOTES for ED documentation

[BAM!]

My hospital network it trying to push this "OPEN NOTES" idea. Patients would have full online access to our ED physician notes. Naturally this is not advantageous for physicians nor the hospital and will lead to more complaints and potential lawsuits. We already have 3 audiences in our notes -- other physicians, lawyers, and billing. We don't need a fourth.

The hospital is saying this is becoming a community standard. Is this true? Does your hospital have "open notes"?

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[Tenk]

Yeah this is common with epic and other newer EMRs. It’s fine. It’s actually hilarious sometimes because people who test positive for stuff like meth will request we remove it from the chart because, of course, they never did meth.

 

[gutonc]

We have it. In Epic there's a button for "Share w/ Patient" that comes pre-selected. I unclick it every time for the reasons you point out. I waste enough time (not in EM) explaining the meaningless crap radiology puts in their reports that my patients get hung up on.

 

[clibby]

This will be the standard of care. ONC finalized the rules on information blocking which define that it is illegal to prevent the sharing of EHR data for legitimate purposes with few exceptions. Combined with HIPAA laws which give patients access to their data and the need to have patient portals for EHR incentive programs, it essentially requires that healthcare practitioners, hospital systems, etc. must provide healthcare data to patient including notes via a portal. Some exceptions include things like psychiatric notes, under 18 privacy concerns, security issues, if the patient doesn't want access, and a few more.

Personally, I don't mind. I treat my notes like I treat social media: don't put anything in them that you wouldn't mind the whole world seeing.

 

[AMEHigh]

I’m not EM, but this is pretty standard.
It’s not a big deal.
As far as I know it hasn’t lead to more lawsuits. Is there any info to the contrary?

 

[WilcoWorld]

Your unease is understandable, that's how I felt when I first encountered this.

But then I realized that I don't chart anything I wouldn't be willing to tell the patient in plain language and it stopped bothering me.

 

[PTPoeny]

I have been a couple of places that used it. Lots of concerns before it went live and then it wasn't that big of a deal.

As a patient leaving such a system when I graduated residency it made it super easy to make a CD with a PDF of my medical records and not have to wait on faxing when I established care after moving

 

[southerndoc]

Even if a hospital doesn't allow online access, patients can still request it. You'd be surprised how many patients request their records.

Like others have mentioned, I don't put stuff in a patient's note that I wouldn't want them reading. However, that doesn't mean I won't honestly document a chart... frequently with quotes.

 

[Gastrapathy]

We’ve been “open” for a couple years and it hasn’t even come up for me with a patient yet.

I don’t think it is likely to increase malpractice claims. If anything, the fact that they read your note might protect you from some avenues of attack. I suspect you’ll find it’s much ado about nothing.

 

[Apollyon]

Even if a hospital doesn't allow online access, patients can still request it. You'd be surprised how many patients request their records.

Like others have mentioned, I don't put stuff in a patient's note that I wouldn't want them reading. However, that doesn't mean I won't honestly document a chart... frequently with quotes.

'The patient said the following to me: "You dick!" I then exited the room.'

 

[deleted859535]

We also have the option in our Epic deployment, but it is not preselected. I have not used it yet. No push here for emergency medicine yet. Likely not a big deal, but I don't want anything that might increase the rate of chart amendment requests or complaints for stupid reasons.

"Yes I WAS in acute distress! Yes I did have pain when he pushed on my belly! Yes I was in respiratory distress! What does such and such mean?" Sorry, too busy in EM for this.

 

[southerndoc]

'The patient said the following to me: "You dick!" I then exited the room.'

Sometimes worse. I'm known for my candor in medical decision making and for patient history.

 

[Apollyon]

Sometimes worse. I'm known for my candor in medical decision making and for patient history.

Oh, I know! The funny thing is that the SDN censor will catch what we put verbatim in the chart. Like, "The patient stated, "Go **** yourself", and absconded from the department."

 

[thegenius]

As long as patient's can't read preliminary notes, and only finalized notes - as noted above they can request their documents and sometimes do.

If I have a bad patient encounter I definitely document it in detail. Quotes, paraphrasing, etc. It's my representation of what happened. I would say it under oath if I remembered.

 

[Groove]

How is this any different from a pt requesting all the documentation from medical records? Pt's can easily read your notes this way. Or do you mean it gets printed out for them on discharge? I've never heard of "open notes". Always document as if you anticipate the pt will read the note because they often times do.

 

[AMEHigh]

How is this any different from a pt requesting all the documentation from medical records? Pt's can easily read your notes this way. Or do you mean it gets printed out for them on discharge? I've never heard of "open notes". Always document as if you anticipate the pt will read the note because they often times do.

No it doesn’t get printed in my experience. But with Epic/my chart for example if the patient logs in to their account they can see the note.
Yep it’s the same as if a person requested their records.

 

[Vandalia]

Much ado about nothing.

Nearly thirty years ago in the AF as an SGH (don't worry about the term if you are not AF) I spent a small but significant amount of time dealing with people who had obtained their medical records. "No, 'SOB' does not mean what you think it does, it means 'shortness of breath."

So this is not something new. I also asked for a change in my records after a recent physician visit. They had me down as a "smoker", and since I have never smoked, and it could theoretically be used to jack up premiums/deny my wife a life insurance payment, I asked that it be changed at my next visit.

Our primary care people have had records and test/imaging results online for years and they don't report any problems. The person who will call and ask if they should be worried their MCHC is elevated would have called about something else anyway.

 

[BoardingDoc]

in the AF as an SGH (don't worry about the term if you are not AF

For everyone else who was obviously curious about what SGH means in the context of "here's a cryptic acronym, but totally don't worry about what it means," in the context of the air force, it means medical chief of staff. What the actual letters stand for, I haven't been able to find out in the past 5 minutes of googling. If this derails the thread, I blame @Vandalia

 

[Vandalia]

Since you asked, it is an office symbol.

In the real world, you tell someone, "drop it off with Meg", and everyone knows who Meg is. In the military, that doesn't quite work with everyone constantly moving, so "office symbols" are used instead. Each service has their own version, and it also helps tell where they fit in the organization.

At a hospital,
SG=Commander
SGH=Chief of Hospital Services (read Chief of the Medical Staff)
SGP=Flight Surgeons
SGD=Dentist
SGN=Nursing
SGA=Administration

The same flows down through the organization. For example, SGHE would be the Emergency Medicine Department. Or if the place was large enough, you might have something like, MGMC/SGHPC. Where MGMC was an acronym for "Malcolm Grow Medical Center" (the hospital at Andrews AFB outside of D.C.) and the office symbol would be for Pediatric Cardiology.

SG=Hospital Commander
SGH=Director of Hospital Services
SGHP=Pediatrics Department
SGHPC=Pediatric Cardiology.

So if you had a problem with the pediatric cardiologist, you would address a letter to MGMC/SGHPC and it would find its way to that clinic. You can also work the office symbol backwards to find out who is the boss of who. So in the unlikely event the EM department had to thrash out an issue with pediatric cardiology, SGHE would work it out with SGHPC, no matter if the actual people who started it have left and are half way around the world; and if you can't you can escalate it to SGH who would.

Now are you sorry you asked?

Now since that wasn't complicated enough, that was the olden, olden, olden days. The military decided to be more military, so they broke things up into squadrons and groups, which added an even more complicated structure.

EDIT: For those who are younger, SGH is now a wimpy "Chief of the Medical Staff" staff position where they sometimes dump people who can't be trusted with anything else. However, decades ago, he had line authority for anything that even remotely touched "medicine" in the hospital. He - it was always a he with maybe one exception - would be the de facto deputy commander and it was the proving ground for hospital commander. If you could handle SGH, then you would get a hospital, if not, well....

 

[DeadCactus]

Personally, I think you shouldn't chart things that you wouldn't want your patient to read. I don't see the value in charting quotes, play-by-play narratives of interpersonal conflicts, accusations of malingering, etc. Medical professionals can read between the lines quite well without the colorful details that can start to show your negative perceptions of the patient between those same lines.

 

[thegenius]

Personally, I think you shouldn't chart things that you wouldn't want your patient to read. I don't see the value in charting quotes, play-by-play narratives of interpersonal conflicts, accusations of malingering, etc. Medical professionals can read between the lines quite well without the colorful details that can start to show your negative perceptions of the patient between those same lines.

But sometimes we do!

On a parallel thread...I had this encounter 1 year ago. It was a terrible encounter and the pt was a dick. This is what I documented....with a few edits for HIPPA purposes:

22 yo man returns to ED after being discharged an hour earlier with a number of complaints 1) why no blood tests were run on his previous visit, 2) is the sore on his lip herpes, 3) headache and vomiting earlier today. I saw him about one hour ago and answered question #1 and #2. He never complained of #3.

On this return visit he is being manipulative, argumentative, and non-cooperative. I gave him a heartfelt apology for any confusion on the prior visit, and he did not seem satisfied. I asked him whether he accepts my apology and he responded “I don’t think so.” He then proceeded to constantly respond to my questions with his own questions, asking my scribe if those words were recorded in the chart, questioning my role in ordering tests, and regularly refusing to cooperate with a medical screening examination. I asked him repeatedly “do you want a medical screening examination” and he wouldn’t give a forthright answer and instead accuse me of not ordering certain blood tests. I explained to him that this is an emergency department, and we address life-threatening medical problems (as I said numerous times before) and we ended up having this thoroughly circuitous and unproductive conversation. He then called police while in the ED (and they arrived too), and the police implored him to cooperate with a medical screening examination, of which he refused and then said he wanted to press charges. I gave patient ample opportunity to comply with an MSE (as witnessed by ~half the ER nursing staff, security, and two police officers) and ended up discharging him..

 

[Apollyon]

Personally, I think you shouldn't chart things that you wouldn't want your patient to read. I don't see the value in charting quotes, play-by-play narratives of interpersonal conflicts, accusations of malingering, etc. Medical professionals can read between the lines quite well without the colorful details that can start to show your negative perceptions of the patient between those same lines.

That's nice and all, but, really? Admit that some people are just not good. When you use their own words, and not your opinion, that is much more clear, and, also, honest. This reminds me of an episode of Law & Order, where there is a witness that, supposedly, doesn't speak English. In the US, it was Spanish, but, in the UK series, it was French. Regardless, because the person says he doesn't speak English, there's an interpreter. Interpreter says "X", and the witness says, in English, "Hey! I didn't say that!"

Expecting people to "read between the lines" gives them (even if medical professionals) too much credit. That, in itself, is somewhat dishonest. Say it clearly, even if you might find it tawdry or distasteful.

 

[southerndoc]

If the patient doesn't want it in their chart, then they shouldn't say or act a certain way.

 

[AMEHigh]

Personally, I think you shouldn't chart things that you wouldn't want your patient to read. I don't see the value in charting quotes, play-by-play narratives of interpersonal conflicts, accusations of malingering, etc. Medical professionals can read between the lines quite well without the colorful details that can start to show your negative perceptions of the patient between those same lines.

I actually think quotes are better because that takes out the reading in between the lines.

Instead of saying "pt appeared angry," I’ll say "pt said go suck a d1ck" and left the room.
Same with sexual stuff. Instead of saying "pt hit on me," I’ll say pt "asked if he could have my number and send naked pictures."

I think it’s more clear and adds to the record if you just quote. It’s especially helpful to have a record if we need to discharge someone from our practice after repeated instances of such behavior.

 

[Brigade4Radiant]

A medical chart is in a patient’s diary. You document things at the patient states if they don’t want certain interventions or if they don’t agree with your plan. Because it also affects you personally and professionally.

 

[alpinism]

Yeah I was taught to always quote the patient's exact words especially in the case of violent or abusive patients.

The last thing you want is to have them file a complaint and there's no evidence of their behavior in the chart.

 

[Vandalia]

Personally, I think you shouldn't chart things that you wouldn't want your patient to read. I don't see the value in charting quotes, play-by-play narratives of interpersonal conflicts, accusations of malingering, etc. Medical professionals can read between the lines quite well without the colorful details that can start to show your negative perceptions of the patient between those same lines.

Perhaps medical professionals can "read between the lines." However, a judge or a jury might not.

The correct standard is that you should be able to defend everything you chart.

"The patient was told she would not receive any opioid pain medications, at which point she started screaming, called the physician and the staff numerous profanities and threatened to "blow this f**** place up. At which point she left AMA."

That is far more reliable, and defensible on many levels than, "the patient was upset and left."

In any legal setting - and medical records are a legal document - facts are preferred to opinions and conclusions. Chart objective behavior. In my example, how do you know she was upset? That would be an assumption on the part of the physician.

Chart objective behavior.

 

[thegenius]

Perhaps medical professionals can "read between the lines." However, a judge or a jury might not.

The correct standard is that you should be able to defend everything you chart.

"The patient was told she would not receive any opioid pain medications, at which point she started screaming, called the physician and the staff numerous profanities and threatened to "blow this f**** place up. At which point she left AMA."

That is far more reliable, and defensible on many levels than, "the patient was upset and left."

In any legal setting - and medical records are a legal document - facts are preferred to opinions and conclusions. Chart objective behavior. In my example, how do you know she was upset? That would be an assumption on the part of the physician.

Chart objective behavior.

Haha yep. I agree chart objective behavior.

I guess what I wrote 3-4 posts above wasn't objective, but it was close.

 

[DeadCactus]

Who cares if the patient was angry, let alone that they told you to suck a dick? Who cares if they asked for naked pictures? Do you get a pass on bad outcomes because the patient was a jerk? Reading between the lines that a patient was difficult doesn't mean you can't be explicit about your decision making and attempts to provide appropriate medical care. There is no reason someone should be able to look at your note and tell you thought a patient was an dingus but that's exactly what people put between the lines.

"Ladies and gentleman of the Jury, clearly Dr. X was angry about poor Mr. Y's behavior. Look how carefully he made sure to document these extraneous details that have nothing to do with his medical decision making. Well, unless he altered his medical decision making based on Mr. Y's behavior. Sure, maybe Mr. Y's behavior could have been better. But he was in pain and scared and felt he was not being taken seriously. Did he deserve to die for that? Would Dr. X have tried harder to convince him to stay if he was a more likeable patient? Was Dr. X overly eager to be rid of the patient. It certainly seems so."

Choosing specific quotes and overly detailed descriptions is not objective. You didn't quote any of the rest of the visit, your physical exam is described in a few short phrases. Quoting specific phrases and giving a play-by-play of certain actions is giving a subjective opinion on what you thought was important. You're telegraphing that you think their behavior was an important part of the medical decision making and between the lines that you found them unpleasant.


"Patient declined additional history and physical. They did not wish to elaborate on why. I explained the risks and my concerns regarding the need for additional evaluation but they maintained their refusal. They demonstrated no evidence of impaired capacity and desired to leave immediately. They left the emergency department prior to signing AMA documentation."

"Patient's behavior made me concerned for the safety of emergency department staff. I requested security's presence. Patient's evaluation and treatment were complete, no urgent or emergency medical problems were identified. No evidence of impaired capacity. I explained the patient's results and recommendations to him. I sought and answered and further questions he had. I requested security assist in discharging the patient home."

What value would colorful quotes add to these examples? Is there potentially some role for exact quotes? Maybe, I think it's vastly overstated though. I still maintain that if you're charting things you don't want a patient to see, you're charting things you don't want a jury or peer review to see.

 

[WilcoWorld]

Well, it's also kind of fun sometimes.

 

[Apollyon]

Again with the "read between the lines". That is too much assumption.

And, putting pt comments in verbatim IS objective (by definition), but, choosing which ones to use, yes, that is subjective.

 

[BAM!]

This will be the standard of care. ONC finalized the rules on information blocking which define that it is illegal to prevent the sharing of EHR data for legitimate purposes with few exceptions. Combined with HIPAA laws which give patients access to their data and the need to have patient portals for EHR incentive programs, it essentially requires that healthcare practitioners, hospital systems, etc. must provide healthcare data to patient including notes via a portal. Some exceptions include things like psychiatric notes, under 18 privacy concerns, security issues, if the patient doesn't want access, and a few more.

Personally, I don't mind. I treat my notes like I treat social media: don't put anything in them that you wouldn't mind the whole world seeing.

Thanks for the response, which is the answer I was looking for.

To reiterate, apparently this is all a response to new rules set out by the Health and Human Services Office of the National Coordinator for Health Information Technology and CMS in order to implement provisions of the Cures Act. The call it, Cures Act Final Rule.

We will all be subject to open notes by Nov 2, 2020. Looks like I'll be using more verbatim patient quotes.

On a side note, does this mean I have to start doing physical exams?

 

[AMEHigh]

Who cares if the patient was angry, let alone that they told you to suck a dick? Who cares if they asked for naked pictures? Do you get a pass on bad outcomes because the patient was a jerk? Reading between the lines that a patient was difficult doesn't mean you can't be explicit about your decision making and attempts to provide appropriate medical care. There is no reason someone should be able to look at your note and tell you thought a patient was an dingus but that's exactly what people put between the lines.

"Ladies and gentleman of the Jury, clearly Dr. X was angry about poor Mr. Y's behavior. Look how carefully he made sure to document these extraneous details that have nothing to do with his medical decision making. Well, unless he altered his medical decision making based on Mr. Y's behavior. Sure, maybe Mr. Y's behavior could have been better. But he was in pain and scared and felt he was not being taken seriously. Did he deserve to die for that? Would Dr. X have tried harder to convince him to stay if he was a more likeable patient? Was Dr. X overly eager to be rid of the patient. It certainly seems so."

Choosing specific quotes and overly detailed descriptions is not objective. You didn't quote any of the rest of the visit, your physical exam is described in a few short phrases. Quoting specific phrases and giving a play-by-play of certain actions is giving a subjective opinion on what you thought was important. You're telegraphing that you think their behavior was an important part of the medical decision making and between the lines that you found them unpleasant.


"Patient declined additional history and physical. They did not wish to elaborate on why. I explained the risks and my concerns regarding the need for additional evaluation but they maintained their refusal. They demonstrated no evidence of impaired capacity and desired to leave immediately. They left the emergency department prior to signing AMA documentation."

"Patient's behavior made me concerned for the safety of emergency department staff. I requested security's presence. Patient's evaluation and treatment were complete, no urgent or emergency medical problems were identified. No evidence of impaired capacity. I explained the patient's results and recommendations to him. I sought and answered and further questions he had. I requested security assist in discharging the patient home."

What value would colorful quotes add to these examples? Is there potentially some role for exact quotes? Maybe, I think it's vastly overstated though. I still maintain that if you're charting things you don't want a patient to see, you're charting things you don't want a jury or peer review to see.

I’m not an ED physician, but I put quotes for not just "bad" behavior. If I think it’s relavent then I quote it.

Obviously you can’t defend bad outcomes because someone was mean to you but you can paint a clear picture of what happened. And even if you don’t put exact quotes I think it’s better to say patient yelled profanities and refused the exam than saying the patient was upset.

So for me it helps to remember patients when I look back at notes for when I see them the next time and it helps to document the case clearly if we need to dismiss the patient from our practice.

I don’t chart anything I don’t want a patient or other peer to see. And for me that means charting objectively with quotes as needed so there’s no reading in between the lines.

 

[BAM!]

Additionally, my understanding is that psychiatric notes aren't subject to ONC's new rule.

It's no secret we see our fair share of psychiatric illness. Are any of you aware of legal provisions that disallow patients from having online access to ED physician notes if there is a component of psychiatric illness or axis II personality disorder complicating the encounter?

 

[WilcoWorld]

Thanks for the response, which is the answer I was looking for.

To reiterate, apparently this is all a response to new rules set out by the Health and Human Services Office of the National Coordinator for Health Information Technology and CMS in order to implement provisions of the Cures Act. The call it, Cures Act Final Rule.

We will all be subject to open notes by Nov 2, 2020. Looks like I'll be using more verbatim patient quotes.

On a side note, does this mean I have to start doing physical exams?

Nah, you've just got to make sure you're documenting a "no touch exam".

 

[namethatsmell]

Who cares if the patient was angry, let alone that they told you to suck a dick? Who cares if they asked for naked pictures? Do you get a pass on bad outcomes because the patient was a jerk? Reading between the lines that a patient was difficult doesn't mean you can't be explicit about your decision making and attempts to provide appropriate medical care. There is no reason someone should be able to look at your note and tell you thought a patient was an dingus but that's exactly what people put between the lines.

"Ladies and gentleman of the Jury, clearly Dr. X was angry about poor Mr. Y's behavior. Look how carefully he made sure to document these extraneous details that have nothing to do with his medical decision making. Well, unless he altered his medical decision making based on Mr. Y's behavior. Sure, maybe Mr. Y's behavior could have been better. But he was in pain and scared and felt he was not being taken seriously. Did he deserve to die for that? Would Dr. X have tried harder to convince him to stay if he was a more likeable patient? Was Dr. X overly eager to be rid of the patient. It certainly seems so."

Choosing specific quotes and overly detailed descriptions is not objective. You didn't quote any of the rest of the visit, your physical exam is described in a few short phrases. Quoting specific phrases and giving a play-by-play of certain actions is giving a subjective opinion on what you thought was important. You're telegraphing that you think their behavior was an important part of the medical decision making and between the lines that you found them unpleasant.


"Patient declined additional history and physical. They did not wish to elaborate on why. I explained the risks and my concerns regarding the need for additional evaluation but they maintained their refusal. They demonstrated no evidence of impaired capacity and desired to leave immediately. They left the emergency department prior to signing AMA documentation."

"Patient's behavior made me concerned for the safety of emergency department staff. I requested security's presence. Patient's evaluation and treatment were complete, no urgent or emergency medical problems were identified. No evidence of impaired capacity. I explained the patient's results and recommendations to him. I sought and answered and further questions he had. I requested security assist in discharging the patient home."

What value would colorful quotes add to these examples? Is there potentially some role for exact quotes? Maybe, I think it's vastly overstated though. I still maintain that if you're charting things you don't want a patient to see, you're charting things you don't want a jury or peer review to see.

I can see your point. But then by the same logic--of not wanting to seem too subjective--than why chart anything? It can be argued that much of what we chart has subjectivity involved.

The purpose of quoting the patient at times is to simply highlight the reality of a heightened situation in as clear and honest a way as possible. In your version, "Patient's behavior made me concerned for the safety of emergency department staff. I requested security's presence."...what about that behavior made you concerned? If you say the patient spoke "rudely" or "threatening" or something then a layperson juror could think, "jeez, that sounds subjective and maybe the doc just has a thin skin." But if you quote the patient saying "F**k you all. I'm going to my car, get a knife, and cut you all up"...then there's less room for imagination for people who weren't there with you. It gives facts and context to explain decision making.

I do agree that you should chart assuming an admin or jury could review it later on. So even when I quote a patient saying "I'm going to find a way to kill all you people tonight" I still include things in the chart about how I was worried about the patient and still tried to act in their best interests and defuse the situation in as safe a way as possible. I would feel 10000% ok if the patient, their family, the hospital CEO, and a jury read that note. At the end of the day, somebody can complain about anything and/or try to sue you for anything. I just try to do the best I can do by 1) making a legit attempt to do right by the patient in spite of him/herself while still protecting my staff and 2) chart in such a way that when somebody inevitably tries to complain/sue and an admin or lawyer reviews the chart...I never hear about it because they understand what actually happened from my note and the inquiry ends there.

 

[turkeyjerky]

Who cares if the patient was angry, let alone that they told you to suck a dick? Who cares if they asked for naked pictures? Do you get a pass on bad outcomes because the patient was a jerk? Reading between the lines that a patient was difficult doesn't mean you can't be explicit about your decision making and attempts to provide appropriate medical care. There is no reason someone should be able to look at your note and tell you thought a patient was an dingus but that's exactly what people put between the lines.

"Ladies and gentleman of the Jury, clearly Dr. X was angry about poor Mr. Y's behavior. Look how carefully he made sure to document these extraneous details that have nothing to do with his medical decision making. Well, unless he altered his medical decision making based on Mr. Y's behavior. Sure, maybe Mr. Y's behavior could have been better. But he was in pain and scared and felt he was not being taken seriously. Did he deserve to die for that? Would Dr. X have tried harder to convince him to stay if he was a more likeable patient? Was Dr. X overly eager to be rid of the patient. It certainly seems so."

Choosing specific quotes and overly detailed descriptions is not objective. You didn't quote any of the rest of the visit, your physical exam is described in a few short phrases. Quoting specific phrases and giving a play-by-play of certain actions is giving a subjective opinion on what you thought was important. You're telegraphing that you think their behavior was an important part of the medical decision making and between the lines that you found them unpleasant.


"Patient declined additional history and physical. They did not wish to elaborate on why. I explained the risks and my concerns regarding the need for additional evaluation but they maintained their refusal. They demonstrated no evidence of impaired capacity and desired to leave immediately. They left the emergency department prior to signing AMA documentation."

"Patient's behavior made me concerned for the safety of emergency department staff. I requested security's presence. Patient's evaluation and treatment were complete, no urgent or emergency medical problems were identified. No evidence of impaired capacity. I explained the patient's results and recommendations to him. I sought and answered and further questions he had. I requested security assist in discharging the patient home."

What value would colorful quotes add to these examples? Is there potentially some role for exact quotes? Maybe, I think it's vastly overstated though. I still maintain that if you're charting things you don't want a patient to see, you're charting things you don't want a jury or peer review to see.

I agree with a lot of what you're saying, however verbatim quotes from abusive patients are far more effective in defusing admin