@yejnes : Just saw term "ten point review of systems" in another office note. Why does that remind me of what you get at a Jiffy Lube with each visit?
Once upon a time we wrote medical notes to document the patient's status, our analysis and our plans. Today we write notes to meet documentation requirements. Back in the 70s when I learned to write SOAP notes, I would have a separate note for each problem, each with Subjective, Objection, Assessment and Plans. Each note portion made me think about that problem, where we were and where we were going. My notes reflected my thought process. Another physician reading my note quickly understood what I had done and what I had ordered and why.
Today's notes are full of 8 point physical, 10 point review of systems and little true information describing thinking and how that relates to the plan. We document unnecessary information, just because of billing, making our notes obscure and difficult to decipher.
Who developed the concept of 10pt ROS? Can we have a formal shunning procedure and ban that person from the academy?
Why do we spend so much time making the chart look good and less time making the patient look good? You get what you pay for, and we rarely pay for the right stuff.
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Many SOAP notes can be summarized in 1-2 sentences. Most of the charts seem to be written for liability protection and level of care billing. Most of us complain about the mountain of paperwork and thick charts, yet no one tries to reform the system. All the EMRs are doing are creating template notes that have little bearing on how the patient is doing.
It is no wonder that despite all the ranting and raving about long hours at the hospital, we do justice to more files than patients. I hope this trend changes. But what with the high chances of landing ourselves a lawsuit. Let’s keep our fingers crossed.
Part of the problem is evident in your last sentence, “you get what you pay for”. Currently internists get paid for documenting, not for doing.
Part of the problem is the legal idea, “if it isn’t documented it wasn’t done”.
The problem is worse with electronic records which can be templated, cut and pasted. I’ve seen charts where every outpatient note includes a physical exam which states that the tympanic membranes were normal, even if a visit a few months previously made the same statement and both visits were for BP management. I’ve seen H&P’s where the past medical history is a computer generated coding list and includes such nebulous statements as “coronary artery disease” (without specifying whether that means a prior MI, angina, stent placement, cath, or other info) and multiple items relating to the same problem (chronic low back pain, DJD, DDD, chronic pain syndome, osteoarthritis).
I’ve also seen a note from an alcohol treatment counselor, where the consult was placed to arrange outpatient alcohol treatment and could have been answered in a sentence, such as “Patient set up for AA in local community”, that was over 500 lines long.
This results in charts full of garbage that have no narrative content and in my opinion is a disgraceful situation. However, to change it would not be simple and would require changing the current billing and legal systems.
Can you imagine that if, instead of 10 minutes making sure that your note meets all the billiing requirements, we spent an additional 5 minutes talking with patients and reviewing care plans. The world would be a better place. I’m not sure what the formal policy on shunning is, but I say go for it!
I can bet that every hospital has more computers than patients and more IT staff than nurses.
How did we end up in this documentation mess? I agree the current system does not work but whoever/whenever came up with this hopefully did it with some good intentions. Obviously, you cannot anticipate all the problems something new will create and therefore an ongoing evaluation of new policies and procedures is essential and policy makers should be willing to addres the important unanticipated consequences. This will apply to “p4p” and most other things we do in medicine.
So, if your nurse said "I gave Ms. Smith her x medication for the correct dosage," but she did not document it- should you just believe her? You can argue that in a court of law? No. We will forever have to live with the "If it wasn't documented it wasn't done" mentality. Because YOU wouldn't trust a clinician's statement as much as the next person when a patient has an adverse reaction when no information has been documented.
The templates are there to serve as a guide, not a hinderance. If you don't like your "guide" then work to change it. You shouldn't look at this "guide" as a form of billing, but rather as a guide in making sure you have covered your bases when seeing the patient. Proper documentation can lead to quality care and positive patient outcomes. If a physician is providing the best of care they will not simply copy and paste an entire chart into a new visit. This is not the purpose of a template.
If you want to increase your bonus or paycheck for the year while also being efficient in your practice you will open up your mind to templates and/or documentation efforts. If you don't like something, well work with the people that can change it. You will only hurt yourself and your bottom line if you are closed minded to documentation improvement efforts.
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