I attended part of a workshop on hand-offs yesterday. The workshop was excellent, but made my think about root causes. One of the speakers focused on making your rationale explicit during hand-offs, e.g., check the BMP – the creatinine is 2.0 and we expect it to decrease. If it increases then do …
This information used to be in the chart. We were taught to write informative notes that included our reasoned assessment of the current situation and our explicit plans related to that assessment.
Too often I do not see such notes in 2009. The notes take as long to write, but are dominated by billing requirements. We see review of systems and physical exam repeated everyday, even when this recording is a clear waste of paper.
We have a significant degradation of notes to meet bean counter requirements. I know of no physician who thinks that the new notes are necessary for patient care. I submit that a clear explication of assessment and plans would make transfer of information much easier than the notes I read today.
This represents just another intrusion of Medicare and the insurance companies. Of course no one will address such issues in the health care reform debate. Could the degradation of our notes present a patient care risk?
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of course it’s a patient care risk. Today’s EMR generatated templated notes are bad enough, fill them with worthless billing bullet points and it’s even worse.
Useful information is buried in a sea of worthlessness, even if it’s there at all.
Considering the importance of accessing previous information when deciding on current treatment plans, this is a very obvious patient safety and quality issue.
Agree with Pcb completely. I work in the Emergency department, and am astonished at how completely useless are the notes our EMR generates. With auto-filled past medical/surgical/social histories that are more often than not incorrect or incomplete, medication blow-ins that are pretty much useless, and all of the other billing requirements that hinder finding any useful information for follow up. I’ve taken to dictating as many of my notes as I can, just so they can (hopefully) be useful again to the next physician who comes along and might want to know what happened with their patient.
Write whatever you want in the patient and bill your inpatient notes using time codes.
I discuss this frequently with medstudents & residents – the evolution of the office note. It started out as a reminder to yourself in the future & fit on 3X5 card, .e.g, “Here for HTN recheck, BP 142/98, lisinopril increased to 20mg daily, RTC 6wks.” This is adequate for what I as an MD need to know. Then the note also had to serve as a legal document to defend yourself. Next it also had to become a billing document which made it even longer. Now the note is primarily a billing document to justify an E&M code. It has terrible “signal to noise” ratio. I get multi-page notes faxed from the ER that have plenty of bullets to justify the level 4 code for abdominal pain, but I don’t have a clue what the final diagnosis and plan are from looking at the endless bullets. It’s become a great billing document, but frequently a useless medical document.
The best record would be a continuous record. For inpatients, each note would be updates to changes in the patient, such lungs now clear or improved air movement. Some of the specialists and primary care doctors now have admission order templates and daily SOAP templates for inpatients, which are simply check off forms that work for billing a higher level of care but do not really state how the patient is doing.
My area has a lot of doctors who have left, secondary to the high malpractice insurance. I get outpatient records that simply are long billing notes of check off boxes that do not tell me how the patient really is doing with 1-2 sentences at the end about documenting side effects and risks with the patient. The ideal office note, which is easily done with computers, would be update notes. This could be that a diabetic has controlled sugars with an A1C of 6.2 and no changes. Unfortunately these short notes, which would allow the physician more time with the patient, do not hold up in Medicare/HMO/PPO insurance audits or in malpractice cases. The current system encourages multipage notes that are more about stating risks and side effects to the patient than about treating the patient.
With the EMRs that many specialists have, I am getting 2-3 page notes of check off areas with impressive 50-100 different bullet points on the ROS, which likely were not really done but used to makes sure the level of care was billed higher.
Sometime between the 1970s and the 1980s, office visits went from a simple $20 charge and 4×6 card to this extensive process, which does not benefit the patient or the doctor. When I see my uncontrolled diabetics 4 times a year or more, I feel like I am simply documenting the same information over and over again.
Maybe the next best option is to create another note called ‘summary medical note’ that essentially is the note from 20 years ago. The first note would include all the BS, and the ‘summary medical note’ is what all the providers will read?? hah. Just more work for us all…
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