Mind Your P’s and Q’s

“Mind your P’s and Q’s” is an English-language expression meaning “mind your manners,” “mind your language,” “be on your best behavior” and “watch what you’re doing.” Early examples of the use of P’s and Q’s may be a reference to learning the alphabet. An early allusion is found in a poem by Charles Churchill, published in 1763: “On all occasions next the chair / He stands for service of the Mayor / And to instruct him how to use / His As and Bs, and Ps and Qs.”

A number of alternative explanations have been considered as more or less plausible. One suggests that P’s and Q’s is short for “pleases” and “thank yous,” the latter of which contains a sound similar to the pronunciation of the name of the letter Q. Another proposed origin comes from the English pubs and taverns of the 17th century. Bartenders would keep watch on the alcohol consumption of the patrons, keeping an eye on the “pints” and “quarts” that were consumed. As a reminder to the patrons, the bartender would recommend they “mind their P’s and Q’s.”

You are probably wondering what this idiomatic expression has to do with anything relevant to our erudite General Surgery News readership. Let me refer you to the 21st-century Cures Act and some provisions that took effect just this past November. The Cures Act is responsible for the implementation of key provisions that are designed to “advance interoperability; support the access, exchange and use of electronic health information (EHI); and address occurrences of information blocking.” This federal rule also mandates that patients have access to their EHI in a form “convenient for patients, such as making a patient’s EHI more electronically accessible through the adoption of standards and certification criteria and the implementation of information blocking policies that support patient electronic access to their health information at no cost.” In plain English, it means that starting Nov. 2, 2020, all patients in the United States will have immediate access to all clinical notes, and thus will be able to read their doctors’ writings and dictations, as well as all laboratory, pathology and imaging reports.

The law means that inpatient and outpatient notes will be released without delay and that patients will have immediate access to testing and imaging results, including results from sexually transmitted disease tests, Pap tests, cancer biopsies, CT and PET scans, fetal ultrasounds, pneumonia cultures and mammograms. This federal mandate, called “open notes” by many, is potentially perplexing and frightening for patients. For example, the term SOB may not be intuitively obvious that it stands for “shortness of breath”! Obviously, the perusal of medical information by patients, families and caregivers without the accompanying counsel of the patient’s clinician is tantamount to “surfing the web,” trying to make sense of unfamiliar information.

Traditionally, medical record notes have served as a conduit of information between and among clinicians and have been important repositories of information to provide a reasonable chronology of a patient’s course through treatment. An additional practical use has been for the accurate coding and billing of patient care. These foundational uses of patients’ records will undoubtedly still hold true. The issue that I am highlighting, however, is that clinicians and all health care institutions have a greater audience for seamless viewing of the entire health record—namely the patient.

It is patently obvious that even without federal mandates, clinicians should endeavor at all times to enter notes that are clear, factual and composed in a thoughtful manner for all those destined to read them. The other important message is to refrain from taking for granted that your notes actually have conveyed your true account of your patients’ clinical encounters. Think about those times that you have written a text, an email message or a social media comment which, when reviewed, had no semblance to your actual intent! Clinical notes and especially operative reports must be considered in the same light. Every patient dictation and entry in the electronic health record must be reviewed for accuracy, truthfulness and sensitivity. This will be a good practice for all of us and should not just result as a consequence of routine patient review. Yes, the time is really nigh to mind our P’s and Q’s.

Dr. Greene is a surgeon in Charlotte, N.C.