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Recording Patient Data: Get to the Point

I have read Dr. Conti’s editorial with interest.1 This is not only a timely editorial, but it also emphasizes the deviation of current history recording from what has been traditionally taught. I have been bewildered not only by the redundancy but also some abbreviations that are now commonly used (e.g., PERLA [pupils equally reacting to light and accommodation] and HEENT [head, eyes, ear, nose, throat]. I have personally reviewed notes where head, eyes and ear were not examined but mentioned in abbreviated forms. Similarly there is a tendency for writing PMI (point of maximal impulse) instead of apex beat, as most students incorrectly think it to be synonymous to apex beat. While rounding, I had noted over the years, that the faculty would always go back to read their own notes and they would write as if it is a mode of communication for them only. The idea behind a good history recording is not only to help formulate the thought process but also to write notes that would help in communication with other staff members who will follow you. Any improvement in patient care needs a detailed but well documented history and physical examination, and for this we have to go back to the basics and any forms of abbreviations should be totally avoided.