We speak of physical diagnosis as if the sign and the suggested diagnosis always match. Often they do, for example when we see acromial step off and suspect anterior shoulder dislocation.
But more often there is ambiguity. Most bedside information is non-specific. For example, tachycardia can mean a lot of different things. Later when we look at everything at once, there is the chance to “put it all together.”
But when will you do that? It is necessary at times to give uninterrupted concentrated thinking to a patient’s symptoms and signs. For example, how about the chronic headache patient who saw the chiropractor for neck pain? When you put it all together you might think of vertebral dissection.
Some call this a “cognitive pause,” others just call it medical decision-making, and others focus on the disruptive effect of interruptions.
Many ED groups routinely expect charting to be done at the end of the shift, after the patients are gone.
But charting is a chance to think critically, to put it all together. And sometimes when we do that early in the visit, it can prompt a “lightbulb” moment where we realize the need to check something else.
I advocate real time charting. The act of creating a chart requires thinking. Why not do that while the patient is still in the ED? I think at the end of the visit just before discharge is okay but even better would be right after seeing the patient. The recitation of the symptoms and signs are most accurate at that time and the “cognitive pause” of thinking through the whole presentation then can happen early, when it can change the workup.
It is simply impossible to do that on all patients on all shifts. But this is something we should try to do. The bottom line is that most historical and physical findings are ambiguous. There needs to be an explicit stage after information collection, which is information “integration.”
Take Home Points
-Complex patients require a “cognitive pause”
-It is hard to do that on a busy shift but real-time charting makes it more possible
Check out Mark Jaben EP Monthly April 2013