When would you rather see your record for the first time?
In a big packet of papers, the words cold, clinical, unbending, difficult to understand. Distant. Questions develop, inaccuracies noted, how does one correct? Frustration, calls to the office, time passes.
I am of the opinion it is best to see your record for the very first time in real time with the one who is doing the record keeping. Behind closed doors with the one you seek out, trust, has your best interest in mind. With one who will tell you the truth, even if it hurts. The task of seeing and making your chart, in my opinion has to be shared and symbiotic. Your chart is not a document, rigid, cold and fixed, but rather an expression, a shadow, a snapshot of this moment in time shared, but more.
The multitude of data points collected, such as laboratory results, vitals, referring physician notes, EKG’s, radiology reports or x-rays easily retrieved and displayed, best shared during this time for a mutually beneficial learning experience.
As you go through and review the past histories, memories relived, any inaccuracies corrected the chart links the past, present and future. The chart may then become a better documented representation of a mutually agreed upon moment in time.
When you see your chart for the second time, there will likely be no surprises.