The scroll bar is an honest instrument. It shrinks in proportion to what lies below, and on some clinical notes it shrinks to a sliver, a small grey promise that a great deal more is coming. The eye registers this before it has read a word. There is so much here, the sliver seems to say; surely everything important has been included.
Perhaps it has. The difficulty is finding it.
In the sixteenth of his Provincial Letters, the anonymous pamphlets of 1656 and 1657 in which he defended Port-Royal against the moral theology of the Jesuit casuists, Blaise Pascal apologised to his reader for the length of what he had written: Je n’ai fait celle-ci plus longue que parce que je n’ai pas eu le loisir de la faire plus courte. I have made this one longer only because I have not had the leisure to make it shorter. The sentence is usually quoted as a joke about haste, and it is a good joke. It is also an exact piece of accounting. Pascal understood that shortness is where writing ends, not where it begins; that a long text is often simply the first text, the one that exists before anyone has decided what matters; and that the deciding has a price, which he names with care. Not time, quite. Loisir: leisure, room, a margin of unhurried attention in which a writer can read his own sentences as a stranger will.
Many clinical notes are Pascal’s letter produced at industrial scale. They are long because nobody had the leisure to make them short, and they are read by people with even less leisure than their writers had. This essay is not a lament for a golden age of documentation, which, as anyone who has tried to decipher a handwritten chart can confirm, never existed. Nor is it a case against length as such; an essay of this size would be an odd place to make one. It asks a narrower question, the one the long essay at the root of this series asks of medicine as a whole: where knowledge lives, and whether information, once gathered, ever becomes understanding. On a single page of a clinical record that question takes a small, exact form. Where in the note is the thinking? And why did it become so easy for a note to grow longer while saying less?
Where the Cost Went #
On paper, length had a natural price, and the writer paid it. A hand tires. Ink runs out, and so does patience. A physician writing by hand put down what seemed to matter and not much else, partly from judgement and partly from fatigue. The result was often illegible and sometimes too terse, but it had proportion built into it, because every line cost the person who wrote it.
The electronic record removed that price for the writer. A template can produce a page of structured text from a few selections. A previous note can be carried into today’s with a keystroke. Results can be pulled in automatically, whole tables of them. None of this is sinister; each tool was built to save effort, and does. The cost of length, however, did not vanish. It moved. It now falls on the reader, who must pass through every carried-forward paragraph to discover what is new, and who usually has no way of knowing in advance whether anything is.
The shift has been measured. In 2018, in Annals of Internal Medicine, Lance Downing, David Bates and Christopher Longhurst reported, from a software vendor’s data on notes written in its system around the world, that American clinical notes were on average about four times as long as notes written in other countries. They located the root of the difference less in the software than in regulation and the billing requirements tied to it. In 2022 a study in JAMA Network Open, analysing more than 104 million notes from a large academic health system, found that about half of all the text had been duplicated from earlier text about the same patient, a share that had grown from about a third in 2015 to more than half by 2020. The authors did not blame individual clinicians. They described copying as a reasonable response to a documentation system poorly suited to its task, which seems to me a fair account of why people do it.
There is an older irony underneath these numbers. In 1968 Lawrence Weed published two articles in the New England Journal of Medicine under a title that remains the best short statement of what a record is for: “Medical Records That Guide and Teach.” Weed wanted notes organised around the patient’s problems, with the physician’s reasoning about each set down where the next reader could follow it, and the format that grew from his work, subjective, objective, assessment, plan, gave the thinking a place of its own: the A. That letter survived into nearly every template written since. What the space beside it holds is another matter. A structure designed to make reasoning visible can be filled, with no change to its headings, by text that makes reasoning impossible to find.
When a long note fails its reader, it usually fails in one of four particular ways, and length is the medium of each failure rather than its cause. It can fail in proportion, giving the reason for the visit the same weight as a condition that has not changed in a decade. It can fail in chronology, so that what was found this morning and what was found three years ago arrive side by side, in the same tense, with their dates mislaid. It can fail in source, leaving the reader unable to tell whether a sentence records what the patient said, what the clinician saw, what a machine imported or what an earlier writer believed. And it can fail in reasoning, setting out every finding and never saying which of them mattered, or why. A short note can commit all four failures. Length simply gives them more room to hide, and makes them more expensive to discover.
Five Kinds of Text That Look Alike #
Part of the difficulty is visual, and it is easiest to see in a small invented example. Here are five sentences that might sit together in a hypothetical note about a woman who has come in because she is tired, each followed by a label the real note would not carry.
- She says she has felt tired for about two months and has been sleeping badly. Reported today, by the patient.
- Weight today is three kilograms lower than at the visit in March. Observed today.
- Blood count from December within normal limits. Imported automatically from a laboratory result.
- No history of thyroid disease. Walks daily for exercise. Carried forward from a note written three years ago.
- Fatigue, most likely related to poor sleep. The writer’s interpretation.
On the page as a reader meets it, the labels do not exist. The five sentences share a typeface, a size, a colour and a margin. Nothing in their appearance distinguishes what the clinician saw this morning from what a colleague wrote three years ago, or what the patient believes from what the physician concluded. Yet they do quite different work. The first is testimony, and its authority is the patient’s. The second is fresh observation. The third is a measurement whose currency depends on a date the sentence has nearly lost. The fourth may have been true three years ago and may still be; the daily walking, in particular, is exactly the kind of fact that tiredness erodes, and its presence in today’s note quietly asserts that it has not. The fifth is the only sentence on the list that is a thought, and it sits in the same font as the rest, as though it were one more finding.
The paper chart, for all its faults, had a crude record of origin built into its texture. Different hands wrote in different inks; laboratory slips were glued in and looked like laboratory slips; a specialist’s letter looked typed; a date stamp was a stamp. A reader could often tell at a glance that a page was old, or borrowed, or someone else’s. The electronic note is typographically democratic. Every sentence arrives looking equally new and equally authored, and a reader who wants to know who saw what, and when, must work it out from context, if the context survived.
Jorge Luis Borges wrote a story about a mind with no means of making such distinctions. In “Funes the Memorious” (1942), a young man in Uruguay is thrown from a horse and wakes with a perfect memory: every leaf of every tree, every shape of every cloud, every moment of every day, retained without loss. Funes is troubled that the dog seen at 3:14 in profile should bear the same name as the dog seen at 3:15 from the front. He can reconstruct an entire day; the reconstruction takes an entire day. Borges’s narrator suspects that Funes was not very capable of thought, and gives the reason in a sentence: Pensar es olvidar diferencias, es generalizar, abstraer. In my rendering: to think is to forget differences, to generalise, to abstract.
The total note is Funes’s day. It reconstructs the visit at the scale of the visit, so that reading it takes almost as long as the visit took to have, and it never quite arrives at the generalisation, because generalising requires the writer to forget on purpose: to decide that fourteen unremarkable body systems can be folded into a phrase, that five stable conditions can be named in a line, that one sentence among the five above is the one the visit turned on. The assessment is the place in a note where its writer is allowed, and in fact obliged, to forget well. When that place is filled with more remembering, the note has recorded everything and concluded nothing.
A Note, Twice #
Consider the same hypothetical visit written twice.
In the first version every section is substantial. The history opens with the list of long-standing problems copied from the previous note. A review of fourteen body systems follows, nearly all of them negative, with the tiredness appearing once, in the middle, between two denials. The examination describes every organ system in the complete sentences it used two years ago. The medication list runs most of a page. The assessment names six problems, five of them followed by the word stable, and the sixth, fatigue, most likely related to poor sleep, followed by a list of blood tests that the sentence before it gives no reason to order. Somewhere in all of this is the reason she came, and whatever reasoning the visit produced lies scattered in fragments: a test ordered here, a remark about sleep there, nothing that joins them.
Nothing in that version need be false. What it lacks is proportion: the sense, carried by arrangement and emphasis, of which parts shaped the thinking and which are background.
The second version begins differently.
Main concern today is tiredness for about two months, which she attributes to poor sleep. I am not yet convinced sleep explains it: she has also lost three kilograms since March without trying. The blood tests ordered today are meant to look for a medical cause; if they are normal, the next step is to look more closely at the sleep itself. We will talk when the results are back, by the end of next week. Her other conditions were reviewed and are unchanged.
The rest of the note can follow, as long as it needs to be. Every editorial choice in those few sentences has a reason, and the reasons are worth setting out, because none of them is brevity for its own sake.
The concern comes first, because it is what every later reader will be looking for. The patient’s own explanation is kept, and kept as hers: which she attributes to poor sleep records her theory without adopting it or dismissing it, and a reader can see that she offered it. The writer’s stance is stated in the first person and the present tense, I am not yet convinced, which makes it a judgement someone can disagree with rather than a fact someone must accept. The reason for the doubt is given, and it is the observation from the list of five that would otherwise have sat inert among the others. The tests are attached to a question, so that a reader who sees them ordered also sees what they were ordered to find out, and what happens if they find nothing. What is pending is named, along with when. And the stable problems are not deleted; they are demoted, from six lines of equal weight to one sentence that tells the reader they were looked at and need not detain her.
The second version may not be shorter than the first. If its writer keeps the full medication list and the examination below, it may well be longer by a sentence or two. What has changed is not the length but the location of the knowledge. In the first version it exists only in the writer’s head, and anyone else must reconstruct it from scattered parts. In the second, it sits at the top of the page, in words.
William Strunk’s The Elements of Style, printed privately for his students at Cornell in 1918, gave the language its most famous rule of composition in three words: Omit needless words. The rule is almost always quoted alone. Strunk’s own gloss on it is better, and it is the part that matters here: “This requires not that the writer make all his sentences short, or that he avoid all detail and treat his subjects only in outline, but that every word tell.” The test is not length. It is work. E. B. White, who had been Strunk’s student, recalled in the introduction to his 1959 revision of the book that Strunk had pruned his own remarks so hard that he risked running out of things to say before the class hour ended, and that he got round the difficulty by saying everything three times. It is a fond and funny portrait, and an accidental description of a certain kind of note: an hour’s worth of space to fill, a few true things to say, and the true things said again and again until the space is full.
The Reader Who Was Not There #
A note is written for people who were not in the room, and the most exacting of them is the clinician who must act on it without being able to ask its writer anything.
Imagine her, hypothetically, on a Saturday. She is covering for colleagues across several practices, and a result has come back on the woman from the example, or the patient herself has called to say she feels worse. The covering clinician has a few minutes and a telephone. What she needs from the note is short and specific. What question were the tests meant to answer? What did the physician suspect, and how strongly? What result would change the plan, and in which direction? What is still pending, and whose job is it? What has the patient been told to expect, so that nothing said on Saturday contradicts what was said on Thursday?
The first version of the note contains enough material to answer some of these questions, given time, and answers none of them directly. The covering clinician can see that blood tests were ordered; she cannot see why, or what anyone hoped they would show. She can see six problems, five of them stable; she cannot see which of them was worrying anyone. To act safely she must reconstruct the reasoning from its parts, which is the most expensive thing a note can ask of a reader, and the thing she has least time to do.
There are at least two ways for a note to be incomplete. It can omit a fact. It can also include every fact while omitting the relationship that makes them mean something. A record may contain a symptom, an examination finding, a test result and a plan, and still leave the next reader unable to tell which part of the information changed the physician’s mind. The pieces are present. The reasoning that connects them is missing. That second kind of incompleteness is hard to detect by counting fields. A template can confirm that each section contains text without establishing whether the text answers anyone’s question, and more text may make matters worse if it adds another layer to search before the reader discovers that the connection was never stated.
Consider an invented sentence of the kind that repairs it: The earlier explanation remains possible, but the change described today is why I am reassessing it. It contains almost no raw data. Its value lies in telling the next reader how the data are being used. It also leaves the interpretation open to correction, because a judgement stated plainly can be examined: another clinician can ask whether the change really supports a reassessment, and disagree.
Hemingway described the craft of omission in Death in the Afternoon (1932). A writer who knows his subject well enough may leave things out, and if he is writing truly, the reader will feel them as strongly as if they had been stated; the dignity of an iceberg’s movement, he wrote, comes from only an eighth of it showing above the water. But a writer who leaves things out because he does not know them, he added, only makes “hollow places in his writing.” The distinction is exactly right, and the theory built on it is exactly wrong for a clinical note. Fiction may ask its reader to feel the submerged seven-eighths. A covering clinician on a Saturday cannot act on what she senses the writer probably knew; she has to act on what is above the water. And the long note fails Hemingway’s test from the other side. It does not leave the mass submerged. It hauls the whole berg onto the deck, and the hollow place, the missing because, is hidden somewhere inside the ice. Length conceals a hollow place far better than brevity does. A three-line note with no reasoning looks empty. A three-page note with no reasoning looks thorough.
None of this calls for a universal template. A visit for a sprained ankle does not need conditional plans and a statement of the physician’s confidence, and a structure imposed on every encounter becomes one more thing to fill. The architecture matters where someone else may have to act: where something is pending, uncertain or likely to change. There, a heading that names the open question, a date beside what is awaited and a sentence of honest doubt do more for the next reader than any quantity of completed fields.
The Reader Who Was There #
One reader of the note was in the room, and her reading differs from all the others.
Since the federal rule against information blocking under the 21st Century Cures Act took effect in April 2021, patients in the United States can generally read their clinicians’ notes, often within days of a visit. Not every patient reads every note, and many never open one. But the possibility that she might changes the ethics of the language, because she is the only reader who can check the note against the visit it claims to describe.
What she finds in a long templated note may surprise her. She may read that she denies chest pain, shortness of breath, nausea, vomiting, diarrhoea, in a visit where none of those was mentioned. A template can record a patient denying things she was never asked, because a review of systems left at its default settings produces negatives by the line. To a clinician skimming, those lines are wallpaper. To the patient, who knows perfectly well what was and was not said, they are small untruths about her, signed by her doctor, and they cast a shadow over every other sentence on the page. If the note says she denied something nobody asked about, why should she trust the parts that matter?
She may also find her own words translated past recognition: the tiredness she described as feeling like a battery that won’t hold its charge recorded as fatigue, her own theory about sleep reappearing, unattributed, as the doctor’s conclusion, the worry about her job absent, and the verb denies attached to her like a defendant’s plea. The neighbouring essay on patients reading their notes takes up that vocabulary in its own right. Here the point is narrower. Length that exists to look complete is visible as such to the one reader who knows what complete would have meant. The patient does not need the note to be short. She needs it to be true to the conversation, and proportion is part of that truth: a note in which her main concern occupies one line among two hundred describes a different visit from the one she attended.
Rules, and Beliefs About Rules #
Why do notes stay long when the pressures that lengthened them change? The recent history of American billing offers an unusually clean test.
From January 1, 2021, the rules for coding ordinary office visits changed. The level of a visit could be chosen by the complexity of the medical decision-making or by the total time spent, and the history and examination needed only to be “medically appropriate” instead of tallied element by element. The American Medical Association described one aim of the revision as decreasing unnecessary documentation that is not needed for patient care. An early analysis in Annals of Internal Medicine the following year found that billing patterns had shifted in the first months after the change, while overall documentation length had not. The rule had changed what a note was required to contain. Notes, it turned out, had habits.
Habits of several kinds, in fact, and they are worth separating. There are rules: what billing, law and regulation actually require. There are organisational policies, which may require more than the rules do, for reasons of their own. There are beliefs about rules: what people fear is required, passed down through training and corridor advice, and often outliving the rule that once justified them. And there is the inertia of the template, which goes on producing what it was built to produce until someone with the authority and the leisure rebuilds it. A long paragraph in a note may answer to any of these, and its writer may not know which.
The most durable of the beliefs is a maxim every clinician has heard: if it isn’t documented, it wasn’t done. As a reminder, it is sound; care that leaves no trace cannot be continued by anyone else, or defended. As a theory of records, it invites its own converse, which is false: documented, therefore done. An examination of twelve organ systems recorded in full sentences, in a visit where three were examined, is the maxim turned inside out. The defensive note, written to show that everything was done, ends by making it impossible to tell what was.
George Orwell saw the mechanism in another trade. In “Politics and the English Language” (1946) he complained that modern prose was increasingly assembled from ready-made phrases, fitted together like the sections of a prefabricated hen-house, and that bad writing consisted in gluing together “long strips of words which have already been set in order by someone else.” The image fits the template so exactly that it is hard now to read it without thinking of one. But Orwell’s sharper point concerned the writer, not the reader. Ready-made phrases, he argued, will to some extent think your thoughts for you, and at need will partly conceal your meaning even from yourself. That is the deeper cost of the prefabricated note. It is not only that the reader must wade. It is that the writer may be spared the act of deciding. A menu that offers stable beside every chronic problem will supply the word whether or not anyone judged the problem stable. The judgement is recorded; whether it was made is another question.
Orwell ended his essay with six rules, and the last is the wisest: break any of the others sooner than say anything outright barbarous. It is a rule about the limits of rules, an instruction to keep thinking where the instructions run out. Templates have no sixth rule. They do what they were built to do, and the only place the sixth rule can live is in the person using them.
When Length Earns Its Place #
There is a strong objection to all of this, and it comes from the bedside.
Some encounters require long notes. A patient with five conditions whose treatments interact; a visit spent on a lost home, a sick spouse, a language barrier and a bus route, which together explain why the sensible plan will not work; a symptom whose history took six visits to understand; a decision a patient made against advice, with the reasons she gave and the information she was offered; a conversation about the end of life. These notes should be long, because the situations are, and compressing them does real harm. Compression is how uncertainty disappears, likely dropped to save a word. It is how social context disappears, lives alone standing in for lives alone since her husband died in March; her son visits on Sundays; she no longer drives. The short version is not a summary of the long one. It is a different and worse description of a person.
Anton Chekhov is usually summoned as the patron saint of brevity. “Brevity is the sister of talent,” he wrote to his elder brother Alexander in 1889, and the line has hung over writing classes ever since. A year later Chekhov, a physician by training, crossed Siberia to the penal colony on Sakhalin Island, carried out a census of its inhabitants himself on printed cards, thousands of them, and came home to write Sakhalin Island, a long, dense, deliberately documentary book full of figures and particulars, because what he had found there would not fit into a story. The same talent, the same writer; the subject decided the length. Brevity is the sister of talent. She is not its only relative.
So the argument here is against redundancy and against hidden reasoning, not against words. A long note whose every paragraph does work, preserving a distinction that matters or explaining a decision someone else must carry forward, is a good note, and probably a hard one to write. A short note that omits the reasoning is a bad one, however tidy. The test for any paragraph is the same at any length: does it do new work, and can the reader tell what work it is doing? I would not judge a note by whether it is short enough to admire. I would ask whether its length is earning its keep. Completeness of appearance is a poor reason for a paragraph to exist.
It would be evasive not to apply that test here. A long essay about long notes stands under its own rule. Each section should change what the reader understood from the section before, and where one does not, the reader is owed more than Pascal’s apology.
The Plausible Note #
A new pressure on the note has arrived in the last few years, and it changes the economics again. Software can now listen to a visit and draft its note, or read a long record and produce a summary. In general terms, these tools make length free for the writer in a way the template never quite managed. The template produced visible boilerplate, and copied text often betrayed itself to a careful reader with a stale detail or a date that did not fit. A generated note is fresh every time. It is grammatical, organised and written in the idiom of the visit, and its freshness is easily mistaken for observation.
The risk is what might be called plausible abundance: prose that sounds complete because it is fluent, and that leaves its reviewer with the old question in a harder form. With a template, the clinician had to resist filling the space. With a generated draft, the clinician has to notice that the space has been filled, and decide which of its sentences correspond to anything that happened or anything she concluded. The reasoning problem does not go away. A draft can describe a visit gracefully and still contain no sentence that says why the plan is the plan, because the reason was never spoken aloud, and a machine that drafts from what was said cannot record what was only thought. The separate danger of fluent error belongs to another essay; the concern here is volume, and what volume hides.
There is a sense in which a note drafted from a recording of the whole conversation is Funes again, this time with a microphone. It keeps everything that was said, in order, and it has no reason of its own to forget any of it. Forgetting well, which is to say deciding what the visit turned on, requires a judgement about what mattered, and that judgement belongs to the person who will answer for the plan. The clinician’s work does not disappear when the drafting is automated. It changes shape. Less of it is writing, and more of it is deletion, demotion and the supply of the one sentence the draft could not produce.
The tools could also help, and some of what they might do is exactly what this essay has been asking for. A summary that puts what changed at the top; a draft that marks which text was observed today and which was imported; a review screen that shows the clinician the assessment first and asks her to supply its because: none of these is fanciful, and each would make long records easier to use. What matters most is the question a reviewer puts to every added paragraph, whoever or whatever wrote it. What would the next reader lose if this were gone? If the answer is nothing, the paragraph is not information. It is upholstery.
A Note With a Usable Centre #
Punjabi has a word for what the opening lines of a note should hold. ਨਿਚੋੜ (nichoṛ) is the gist of a matter, its essence or upshot, as in ਗੱਲ ਦਾ ਨਿਚੋੜ, the nichoṛ of what was said. It comes from the verb ਨਿਚੋੜਨਾ (nichoṛnā), to wring out, as one twists the water from a washed cloth. The image carries an argument that the English summary does not. The essence of a matter is not lying on its surface, waiting to be copied off; it comes out only under pressure, by twisting, and somebody’s hands have to do the twisting. Nor is the cloth thrown away once it has been wrung. It is still there, all of it, hung out to dry. A note’s first lines should be its nichoṛ, wrung from the visit by the person who understood it, with the rest of the cloth left within reach of anyone who needs it.
If I try to say what that nichoṛ must contain, it comes to a handful of questions, each of which the second version of the hypothetical note answered, more or less, in a sentence or two. What changed since the last note? What do I think is going on, and why, in at least one sentence of because? How sure am I, and what would change my mind? What is pending, who owns it, and when will someone look? What did the patient say, in her own terms, that the plan depends on? A note that answers those near its top can be as long as the situation requires below them, and its length will be navigable, because the reader knows what she is reading for.
None of this is a documentation mandate, and none of it is quick. Pascal knew why. Among the fragments published after his death as the Pensées is a sentence every writer recognises: La dernière chose qu’on trouve en faisant un ouvrage est de savoir celle qu’il faut mettre la première. The last thing one finds in making a work is what to put first. In a note, the first sentence is the last thing the writer discovers, because it cannot be written until the visit has been thought through, and it is the first thing every later reader needs. The leisure Pascal lacked, and that clinicians so often lack, is spent finding exactly that sentence.
Knowledge, in a clinical record, does not live in its volume. It lives in the sentences that join one fact to another and say what the joining means. Those sentences are few, and hard to write, and easily crowded out. A note that puts them first has done a great deal for a single page. It lets the hurried reader stop at the right place, and it lets the reader who needs more go on, knowing what she is looking for.
Evidence and Editorial Note #
Documented findings. Pascal’s apology for length in the sixteenth of the Provincial Letters (1656–1657), quoted in the original French with the author’s English rendering, and the fragment of the Pensées on what to put first, quoted in French: public-domain texts, stated from standard knowledge. American notes averaging about four times the length of notes in other countries, and the argument that regulation and billing requirements are the root cause: Downing, Bates and Longhurst, “Physician Burnout in the Electronic Health Record Era: Are We Ignoring the Real Cause?”, Annals of Internal Medicine, 2018, as summarized by Stanford Medicine. About half of note text duplicated from earlier text about the same patient, rising from about 33 percent in 2015 to 54.2 percent in 2020, across more than 104 million notes: Steinkamp, Kantrowitz and Airan-Javia, JAMA Network Open, 2022, as summarized by the American Medical Association. The 2021 office-visit coding changes (level by medical decision-making or total time; “medically appropriate” history and examination) and the stated aim of reducing unnecessary documentation: American Medical Association. Early post-change findings of shifted billing but no overall change in documentation length: Apathy and colleagues, Annals of Internal Medicine, 2022, as reported by Medical Xpress. The information-blocking rule under the 21st Century Cures Act, with a compliance date of April 5, 2021: standard regulatory reference. Lawrence Weed, “Medical Records That Guide and Teach,” New England Journal of Medicine, 1968, and the problem-oriented record from which the SOAP format derives: standard history of medicine. Borges, “Funes el memorioso” (1942), its plot details, and the sentence on thinking, quoted in Spanish with the author’s rendering: standard knowledge of the text. William Strunk Jr., The Elements of Style (1918), the rule “Omit needless words” and its gloss, quoted from the public-domain 1918 text; E. B. White’s recollection, in the introduction to the 1959 edition, of Strunk saying everything three times: paraphrased from standard knowledge. Hemingway’s iceberg passage in Death in the Afternoon (1932): paraphrased, with one short quotation. Orwell, “Politics and the English Language” (1946): the hen-house image, the claim about ready-made phrases and the six rules paraphrased, with one quotation of fourteen words. Chekhov’s remark on brevity in an 1889 letter to his brother Alexander, his 1890 travels to Sakhalin, his census of the island’s inhabitants on printed cards, and Sakhalin Island: standard biography. The Punjabi noun ਨਿਚੋੜ (gist, essence) and the verb ਨਿਚੋੜਨਾ (to wring out): standard usage. Vendor representations. The four-fold comparison in the 2018 article was drawn by independent academic authors from data held in an electronic health record vendor’s systems; no vendor’s own claims are relied on, and no vendor is named. Note-drafting and summarizing software is discussed in general terms only.
Recollection and tradition. No specific note written or read by the author is described, and no remembered scene is asserted. The five labelled sentences, the two versions of the note, the covering clinician, and the patient they concern are hypothetical and illustrative; they do not describe a real patient, a real record or a real colleague. The remark about handwritten charts is a general observation about the paper era.
Analysis and forecast. The accounts of where the cost of length moved, the five kinds of text, the readings of Pascal, Borges, Strunk, Hemingway, Orwell and Chekhov, the use of the Punjabi nichoṛ, the distinction between rules and beliefs about rules, and the questions offered for a note’s opening lines are the author’s interpretation and preference as of November 6, 2026; they are not documentation, coding, billing or legal guidance. Independence. This essay is not sponsored by any institution, company, health system or technology developer. It is personal reflection, not medical advice; readers seeking care should contact their own physician’s office.
About the Author #
Kanwar Partap Singh Gill, MD, traces his family roots to Khadur Sahib in Punjab’s Majha region and grew up in Amritsar. He attended Spring Dale School and completed pre-medical studies at Khalsa College in 1994–1996. He earned his MBBS from Sri Guru Ram Das Institute of Medical Sciences and Research in Amritsar in 2002.
He completed PGY-1 at the University of Arkansas for Medical Sciences in Little Rock in 2007–2008, and PGY-2 and PGY-3 with UCSF Fresno at Community Regional Medical Center from 2008 through 2010. He has practiced medicine in California since 2010.
His career has crossed four distinct information eras: predominantly paper-based medicine, early and fragmented electronic records, the integrated-EHR era, and the emerging age of generative and agentic artificial intelligence.