Isn’t it time we started embracing the simplified documentation guidelines that have finally been introduced to ease our billing and coding woes?
These abbreviated guidelines from the Centers for Medicare & Medicaid Services, introduced nearly 3 years ago, are designed to help reduce note bloat, to try to cut through all the things that have made our medical records essentially useless behemoths of documentation. Page after page of notes, endless piles of data and macro templates that someone thought would make our lives, and therefore our patients’ lives, better.
Unfortunately, the amount of work and energy we all put into creating these things far outweighs the mental energy we are ultimately able to put into caring for our patients.
We allowed ourselves to go down a path of creating electronic medical records that put the focus on what was written on the page, rather than our actual thought processes and documentation of what actually happened that day.
I recently saw an example of how a “simple” note can be published by one of the medical societies.
It showed how, in order to achieve a moderate level of complexity for billing, all we really needed to document for the management of two medical problems was a short series of statements showing that the patient was here today to manage those conditions, that they had no problem taking their medication, and that we plan to continue taking these medications.
For example, documentation of an office visit for treatment of well-controlled hypertension may read: the patient takes his medication, notices no side effects, has no referable symptoms, and treatment will continue, perhaps with home blood pressure monitoring, perhaps some relevant lab tests, perhaps patient education.
We should be able to achieve this in just a few lines.
When was the last time you read a subspecialist’s consultation note that just got to the point?
Why do we have to see, in every office note, every past event that happened for the patient that could be related in some way to their condition?
Oncology patients coming in for a dose of chemotherapy don’t need their entire charts re-dictated or re-cut and pasted into today’s note.
I know subspecialists like to see the long trail of events that led to where we are today, but often at the end of their voluminous notes we come to two lines that are relevant – everything is important.
Here today to monitor their cancer, mild side effects from last dose of chemo, now improved, ready for dose number four, check CBC and electrolytes today, CT scan in 3 months.
And how many times have you seen a urology note that contains an incredibly comprehensive system review and physical exam that includes every single organ system, including HEENT, heart, lung, abdomen, and psychiatry?
Do we really need their judgment, mood and insight? Attentive and oriented × 3?
All we really want to see is what they think about the patient’s urology exam.
True, there are certainly times when they should think about things more broadly, when an abdominal exam might make sense for a urologist, but more often than not, cardiovascular and pulmonary exams aren’t really why I feel the patient is seeing them.
I thought their prostate was abnormal, how about you?
Much of this could be answered with a few simple lines, and we’d all be much better off – both the producers of this excessive documentation and those of us who demand it and are expected to read it – if we could just cut to the chase .
In 1862, Victor Hugo allegedly wrote the world’s shortest letter to his publisher, inquiring how sales of his latest book were going.
His publisher replied “!”
This is something we should all strive for.
When I was an intern, rotating through subspecialty services at a hospital, doctors required us to handwrite the patient’s entire pre-dictated discharge summary into our admission notes.
And then when the patient was discharged from that hospitalization, the doctors would require us to dictate the entire course of the hospitalization, including all tests, procedures, and treatments, and add that to another dictated version of the entire previously dictated discharge summary.
Bloat piles on bloat.
Perhaps, as our electronic medical records become more sophisticated, more flexible, and receive our data, we will find a way to put this excessive information into a separate repository, a place where a detailed true medical history, the true hospital course, the true course of a particular disease, can be plot and map, manage and maintain.
Keep today’s notes relevant to what is happening today, what your patient came in for, what was discussed, what you think about what you found and what you plan to do about it.
Why do we need to cut and paste every lab, every procedure result, every imaging test report, into every daily note during a hospital stay or outpatient evaluation?
We can certainly reference it, enter important points, use the functionality of the system to track trends, but constantly repeating the data just creates noise that drowns out the signal, the real signal of clinical care.
Finally, after years of nagging, the bureaucrats in Washington listened to us and removed the requirements for extensive past medical/social/family histories, detailed systems reviews, multi-organ physicals, and agreed to let us just get to the bottom of things. .
Like many things in healthcare, we are slowly adapting, unwilling to change, reluctantly giving up our huge notes.
Perhaps there was a feeling that the longer the note, the more important what we were doing to the patient.
But we can all recognize the truth about it, that everything is in a nutshell.
Cancer is responding, continue current chemo, recheck labs.
Continue to take your current blood pressure medication, work on your diet and exercise.
Prostate examination abnormal, MRI and biopsy recommended.
Isn’t it time we cut to the chase?