Medical Notes
Summary
The accuracy of medical documentation and personal note-taking is critical for inpatient treatment and safety. However, this presents a challenge for observant clinicians for whom writing on Shabbos is forbidden. We will examine a number of methods by which medical records can be kept on Shabbos without violating Meleches Koseiv. We will discuss the following options and propose a practical algorithm for physicians and healthcare workers who find themselves working to save lives in the hospital setting on Shabbos.
Using a shinui (one's non-dominant hand)
Disappearing Ink
"Writing" / typing on an electronic tablet or EMR
Using Printers
Introduction
It is important to address the general guiding principles of what classes of Melacha one can permissibly perform on Shabbos for hospitalized patients and the more granular individual problems and solutions that most commonly arise.
There are a few considerations when assessing any possible concern of shabbos violation.
Is the action in question an Issur D'oraysa or an Issur D'rabbanan?
Although one may "violate" an Issur D'oraysa on Shabbos when caring for a patient whose life is in danger (inpatients), if the situation is not emergent, one should do their best to minimize the number of melachos performed.
1. Using a shinui (one's non-dominant hand),
Halachic literature has two words, "Avodah" and "Melachah," for what we describe in English as "work." Avodah is a general term, while Melachah, in a halachic context, has a very precise meaning. On Shabbat, melachah is prohibited as we have a tradition that melachah refers to the activities which were necessary for the construction of the Mishkan. One of these Melachos was the marking of parts of the Mishkan, called Kesiva (writing), to indicate where each part went, where it was assembled and taken apart during the 42 journeys of the Jewish people through their 40 years in the desert. Koseiv involves creating any meaningful letter or symbol. It doesn't have to be with ink on paper. Using a rubber stamp, carving a stone, or cutting a letter out of paper could all involve Koseiv. However, an important caveat is that this only applies to writing that is done in the normative way as it was done in the Mishkan (i.e Meleches Machsheves). The Mishna in Shabbos (103b) rules that if a right-handed person writes with his left hand on Shabbos, he is exempt mi'deoraisa, as this is a non-normative manner to do "melachah." Therefore, if time permits, writing notes and managing tasks on shabbos with one’s non-dominant hand would be preferable. (maybe a disclaimer about how this works for kesiva and not all melachos - Just a thought.
Some argue that if a person becomes accustomed to writing with their weaker hand, they would be deemed ambidextrous and forbidden from writing with either hand (שבת דף קג). However, as long as the non-dominant hand feels unnatural and is more complex than writing with the dominant hand, it would still be considered a shinui and, therefore, preferable when possible. Others say one may even practice using a shinui, such as wearing thimbles, and that it still constitutes a shinui (Medical Halacha on the Parsha p.137, quoting Rav Aher Weiss).
2. Disappearing or Impermanent Ink
The Mishna in Shabbos (104b) rules that impermanent writing ("Ksav she'eino Miskayem") using a substance such as dust or upon a medium which will not last ("Davar sheEino Miskayem"), such as writing on a food item, does not violate an Issur d'Oraisa. This Halacha is codified by the Rambam (Hilchos Shabbos 11:15). In many cases; it is permitted to violate an Issur d'Rabbanan for the sake of a sick person. Therefore, keeping medical records using a Ksav sheEino Miskayem or inscribing them on a Davar sheEino Miskayem on Shabbos should be permissible for the medical needs of these patients.
The poskim debate how long the legal status of "impermanent" is in the context of Hilchos Shabbos. On the one hand, it is intuitive that writing does not have to last forever to be considered permanent. Based on various halachot in the Rambam and other sources, Rav Shlomo Zalman Auerbach Zt" l (Minchas Shlomo 1:91) posited that one is only liable for Koseiv if the writing will last for several days.
The Minchas Yitzchak (7:13) disagrees, ruling that the permanence of writing is defined by its lasting through the entirety of the Shabbos. He explains that writing is considered permanent if the results of a Melacha last until the end of Shabbos.
On a practical basis, most contemporary authorities view the opinion of Rav Shlomo Zalman that one is only liable for Koseiv if the Ksav will last for several days, as accepted psak.
This leads to a possible solution for writing in the hospital on Shabbos, namely, producing a Ksav, which is Eino Miskayem, via air-erasing pens (link to pen in the online version), a pen whose writing vanishes after hours or days in contact with air. Though this would not be practical for permanent medical records, it is a viable solution for daily lists and tasks.
3. "Writing" on an Electronic Tablet/Digital Records
Much note-taking and task management in a modern hospital are accomplished through computerized electronic health records. The halachic status of the usage of digital devices (such as EMR and computer tablets) for clinical work is a question of how we model the usage of electronic devices on Shabbos. Poskim from the previous generation have wrestled with this matter extensively, and depending on the posek, the use of electricity on Shabbos can be categorized as a violation of an Issur d'Oraisa, a derabanan, or something of a minhag. We must note, however, that according to Rav Shlomo Zalman Auerbach Zt" l (1:9), clinicians may be lenient concerning the use of electricity on Shabbos and rely on the opinion that it is only an Issur d'Rabbanan when necessary, an opinion that is widely accepted in modern poskim. Even Rav Asher Weiss, who holds that electricity is a doraysa (Minchat asher 1:30), holds that it is acceptable to rely on lenient opinions in the interest of pikuach nefesh.
Furthermore, as it relates to Kosev, even though digital writing can sometimes last for longer than "a few days," it is not considered Ksav at all as it is merely a digital representation of the letters and does not have any tangible form making it different categorically than Ksav as it was done in the Mishkan.
Bearing this in mind, Rav Asher Weiss rules (Of Mice and Pens, R Sprung) that being that the Rama requires that we minimize issurim on Shabbos when possible, so it is preferable when medical personnel type on a computer to use their knuckles or with a practiced shinui via thimbles or the like considered a Shinui. Furthermore, although a Shinui is not usually enough to permit Melachos for a patient who is not dangerously ill (according to the Mishneh Berura, according to the Shulchan Aruch Harav, it is permitted) since Ksav on a computer is impermanent and is therefore only an Issur d'Rabbanan, one may be lenient to allow typing with a Shinui even for a Choleh she'ain bo Sakana on Shabbos. Ie; a sick outpatient
Regarding using the computer mouse on Shabbos, it seems logical to say that using one's non-dominant hand would be considered a Shinui, as using a computer mouse requires accuracy and precision and isn't generally done with the non-dominant hand.
A Shinui should also be attempted to be used with smartphones or other touchscreens (e.g., a thimble with a conductive pad). Therefore, digital "writing" is perhaps a better option than air-erasable temporary writing when possible and is preferable to writing with one's left hand or using impermanent ink. Though it would be preferable to ask a non-Jew to turn on the computer or tablet as engaging the circuit is more problematic, if that's not an option, a shinui may be used.
4. Printing
Another salient concern for those on shift or call on Shabbos is whether it is permissible to print labels or forms. Unlike recording data digitally, the end product of printing directly resembles the outcome of kesiva. For this reason, Nishmat Avraham (340:6 p571), quoting Rav Yehoshua Noivirt, rules that printing is biblically prohibited and, therefore, unless it will adversely affect patient safety "amira lenachri" i.e., asking a non-Jewish colleague to print the document is required. If there is insufficient time to have a nonjewish colleague help with printing, Nishmat Avraham writes that one should press print with one's knuckle. It is worth noting that Rav Moshe Feinstein is more lenient in this regard, ruling that printing is not comparable to normative Kesiva as when one does print, one more accurately "causes the writing to occur" rather than writing with one's own force per se. Due to this nuance, Rav Moshe (Techumin vol 4 p423-425) rules that printing is a derabanan. However, most modern halachik authorities rule that printing on Shabbos is, in fact, a de'oraysa and should be avoided.
Conclusion
When doing a non-urgent or time-sensitive task (i.e., a reasonable delay will not compromise patient care), it is preferable to minimize the status of melacha on Shabbos. When documenting for patient care, typing with a shinui is by far the most halachikly ideal option. When that is not possible, the next best is to use an air-erasable pen with one's non-dominant hand, followed by using a regular pen with one's non-dominant hand, followed by using a non-permanent pen with one's dominant hand. Printing on Shabbos is very problematic, and it is best to ask a non-shabbos obliged colleague for assistance, again, unless the delay will compromise patient care.
For further exploration and reading:
https://medicalhalacha.org/2020/06/25/of-mice-and-pens-writing-medical-records-on-shabbos/
Ch 22 Sacred Training https://www.amazon.com/Sacred-Training-Halakhic-Guidebook-Residents/dp/0578441160