I can date a bad habit in my own charts. Around year four of practice I got fast, and “fast” meant the mental status exam from last month survived with a new timestamp. I told myself I would have noticed if something had changed.
I missed a lithium tremor for two visits that way. The patient had it. I had a paragraph that said he did not. The paragraph was prettier than the patient.
Copy-forward is a different error from a short exam
A short MSE on a known, stable person is fine. “Alert, cooperative, speech normal rate, mood ‘tired,’ affect congruent, no psychosis elicited, cognition grossly intact.” That is a human who looked and then stopped writing.
Copy-forward is a paragraph with grooming, eye contact, thought process, proverb interpretation, and a fund of knowledge, identical to April, on a day they came in unwashed and talking over you. I notice the identical ones when I review a chart. A lawyer will notice them faster.
The tell in a stack of my own old notes was the same clause on thought process, word for word, including a comma I always put in the same place. Nobody’s thought process is that loyal.
What I still insist on seeing this visit
Appearance if it would photograph differently than last time. If it would not, I do not write a fashion paragraph.
Speech and motor, because those change on meds and on mania and on Parkinsonism, and they change before the patient has a speech about it.
Mood in their words, in quotes, even if the quote is “fine.” My paraphrase is not their mood.
Affect as I saw it, especially when it does not match the quote. That mismatch is often the exam.
Thought content I actually asked about. If I did not ask about SI, I do not get to write “denies SI” because last month’s note did. I ask, or I write that I did not.
What I no longer manufacture: a full cognitive exam I did not do, a proverb I did not ask, “insight and judgment fair” as a reflex. Fair to whom.
Drafts make this better and worse
A listener in the room will often catch the sentence I would have used as the exam. “I haven’t slept in four days” belongs in the note the way they said it. That is useful. I will keep that.
The same draft will also offer a complete, symmetrical MSE because templates like symmetry. If I am tired, I will accept it. That is how I get last year’s problem back, except now it is fluent.
My rule now is ugly and it works. I delete the MSE block and write six lines from memory of the last five minutes of the visit. If I cannot, I was not examining, I was chatting. Then I go look at the draft and steal only the phrases that match what I just wrote.
If a tool surfaces the exact line they said, I keep the line. I still do not keep the rest of the paragraph as a gift.
The new style of bad chart
We have had ambient drafts long enough that I see this more: every section filled, every visit, including the exam, with the same temperature. It looks responsible. It reads like nobody was in the room.
I would rather sign a short exam I performed than a long exam I inherited. I do not open the chart to look competent. I open it to remember what this person was like on this day. Copy-forward is me refusing to look.