Thursday, July 13, 2017

Paper Medical Records

A paper medical records trifecta; med cards, kardex
and paper chart. Med cards and anything recorded in
Kardex was tossed after their purpose was served.

The importance of the medical record cannot be overstated. Communication of patient information in a usable format has been a priority for many eons. Where else can you find a blow by blow account of surgical treatment, response to drugs, and basic diagnostic information. Whippersnapperrns complain endlessly about electronic medical records and older practicing nurses often  dream of a return to paper records.
Paper records had a certain charm and ease of use, but there were problems with divergent formats, inaccurate data, and unauthorized access, which in some ways, mimics problems with electronic records. At least with paper records nurses were not distracted by a wheeled monster of a computer that followed them everywhere. I don't think there is anything more frustrating than communicating with a person distracted by a  computer screen.

 Most private and charity hospitals were writing progress notes and physicians orders on standard 8 1/2 X 11 size paper. Federal agencies such as the VA medical system had a very unique paper size which was 8 X 10 1/2. This was another example of that infamous VA tag line, "The right way, the wrong way, and the VA way." President Reagan established a government Committee for the Simplification of paper sizes in 1980 and the VA switched to the 8 1/2 X 11 standard.

 When a VA patient was admitted to a private hospital the combination paper sizes were difficult to stack (VA patients always had voluminous records) and the end result was a leaning tower of medical records. How acute the lean angle became was dependent on the volume of the record and the sequence of the odd sized paper. Old nurses always characterized the medical record lean orientation as port or starboard. For some obscure reason port side canted records usually foretold a very difficult patient care situation.

Everyone approached patients with leaning  paper medical records with due caution. These were complex, time consuming patients. One nurse summed it up nicely with this little ditty. "Those patients have every case but a suitcase." It was amusing until one of these patient care conundrums actually brought their suitcase with them to the hospital. It could have been much more morbid. When a patient was not expected to recover one family sent along a three piece suit. "Make sure one of the nurses gives that suit to the undertaker when he comes for Gramps," was the instruction.

Today nurses must be concerned with hacks and computer glitches upsetting the delicate order and sequence of recorded medical data. Paper was not immune from unpredictable  disorder. Old time hospitals were never air conditioned except perhaps for the director's office. This meant that nursing stations were equipped with gigantic fans capable of moving as much air as a Piper Navajo on take off roll. That prop wash at the nursing stations was capable of sending any and all stacks of paper flying off into the wild blue yonder.

I vividly recall one sweltering August afternoon  at Downey VA  Hospital when a stack of newly minted physician's orders was placed on the ward secretary's desk for transcription. Unlike patient care areas where the windows had security screens, administrative zones like nursing stations  went screenless. The massive floor fan actually blew the new orders directly out the open  window. I quipped that the records were "gone with the wind." The head nurse, Lois, had the last laugh and ordered me out of the building for order chasing duty.

Another problem presented by paper  pages was how to organize them into a format for ease of perusal by health care workers. There were clipboards and spring loaded metal chart jackets that worked the best. Later ringed  notebooks came into favor, but there were compatability problems with 2 hole or 3 hole. The VA Health system actually  came up with a  novel and unique system of punching 2 holes into the top of the record and affixing it to the chart with a metal hasp.

Data security is a big deal today with HIPPA this and HIPPA that frequently cited. Paper records did not require mixed character passwords to protect. In hospitals there was someone present by the chart rack 24/7 and physician's offices made a ritual of keeping records under lock and key. When a chart was sent with a patient for a procedure or diagnostic test, the chart was encased in a canvas bag with a locking zipper. Data security at it's finest.

Finally. since paper records were always physically close to the patient they communicated a sense of presence. Nothing tells the story of a harried trauma surgery like an anesthesia record splattered with blood or prep solution. The physical appearance tells the story better than the data recorded. Nurses frequently did their charting while taking a break for a Coke and a smoke. It was common to be ceremoniously greeted by a cascade of cigarette ashes when opening the chart to the last nursing note.
Sometimes the "presence" of paper medical records resulted in a messy situation.


  1. I never had the pleasure/pain of working with an EMR system ~
    Somehow the task of writing out my Nurses Notes was soothing to me...

  2. Me too. I think we were both very fortunate.

  3. There was no drink or food I did not spill on my notes.

  4. How true. Those tattle tale translucent circles on the nursing notes always gave away that someone had greasy hospital cafeteria food brought up to the unit.

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