A record does not change what happens. It changes what can be said about what happened, which turns out to matter in a setting where the entire consultation runs on the patient’s summary of the preceding weeks.
Without a record, the honest answer to how have things been is a general impression heavily weighted toward the last few days. With one, the answer is a specific count over a specific period, which is a different kind of input to a decision.
I used to say it had been fine, mostly. Now I can say which eleven days it wasn’t.
Illustrative composite
- Short beats thorough. The records people sustain for a year are the ones that take under a minute.
- Note the bad days rather than every day. Most of the useful signal is in the exceptions.
- Write what happened, not what you concluded about it. Conclusions age badly; observations do not.
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