When documenting, teach first and always to the patient

I have tried to teach by dictating in front of the patient to ensure accuracy and improve efficiency.  My patients did not like this approach.

When teaching with the EHR conduit-ed via the Chromebook TV, envision yourself disrobed of clothing, self respect asking for help and vulnerable.  Teach with this in mind, gentle, caring and in words that make sense.

Stop using BID or qday, or words like herniorrhaphy.  Use words that are accurate but makes sense to the one person it means the most to.  It is not that hard to do, and when visually shared these words reverberating on the large screen will be most helpful.

I have my routine and start out with the graphs of weights, body mass indexes and blood pressures to break the ice.  Then we review the past medical history and go through line by line to ensure accuracy and also to recall the past together in terms we both understand. Same with social, family histories, allergies and medications.  Most of this information with an existing chart is there already and does not need to be re entered.  Correcting a date, adding a surgery, or updating a medication is very easy to do.  The EHR in this instance is fabulous when used as a visual teaching tool.

The health maintenance section is a perfect opportunity to remind patients the EHR software keeps track of age, gender, diagnosis codes and intertwines with the CDC immunization and US Task force recommendations.  I remind my patients this information is intended only for my eyes however, they can now see I do my job correctly.  This is easy to share and great information to see and hear.

The only time I dictate is when I leave the room, after I have finished with my patient.  But I dictate as if my patient will read his chart, because he will read the summary later via the patient portal.   Again, I dictate in such a way for the patient first in mind, as a teaching moment.

Teach first and document always with the patient in mind, because the record is his.  We are only the caretaker of this information and he will appreciate most when he can learn with you at the visit, especially in a visual format that can be shared.


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