I received this comment today –
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.
This comment came in response to SOAP notes and 10 pt ROS – with a h/t @yejnes
In that post I said:
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.
So I do not understand the comment. My point was that the current documentation requirements paradoxically lead to less informative notes. We are asked to document irrelevant minutiae that do not contribute to an understanding of the patient or his/her problem. The checklist approach to the review of systems and physical examination leads to physicians WASTING THEIR TIME on these requirements rather than devoting their time to writing a useful note.
I stand on my previous statement. Please physicians expand on my thoughts.
{ 5 comments… read them below or add one }
You are 100% correct on your take on documentation. Once it was to communicate progress, thoughts. Now it is to fulfill some obscure requirements. Look at how much of a chart today is completely worthless worksheets, that are filled out by rote (bedsore precaution protocols).
Of what good is that to anyone?
Charts are becoming more difficult to interpret because of this, in most cases.
As for the documentation/legal issue. I work closely with lawyers. Most doctors don't realize this but lawyers can take any bit of information and bend it either way.
IT is not uncommon to hear a lawyer invoke- "If it's not documented, it didn't happen."
It is also not uncommon for a lawyer to invoke, "Everyone knows that not everything that happens is always documented."
Take that for what it is worth.
I've commented on this before. The charts are losing their narrative function. Too often a progress note consists of an opening statement concerning a patient which was written on day #1 and copied for each following note, followed by a templated set of vitals taken by a nurse the last shift (Do any doctors take their own vitals anymore? Electronic cuffs are notoriously inaccurate if the patient has atrial fib or pvc's), followed by a templated and copied med list, templated review of systems, physical exam, and labs. Sometimes these templated notes are not edited so the documented physical exam and ROS is the same from day to day , and it is hard to find out what changes have occurred or what the plan is. This is great for the bean counters and coders but hard for the cross-covering physician to figure out what's going on with the patient. Documentation is a bell-shaped curve. Too little is not good, but too much is confusing, distracting, and wastes time, both to input and to wade through.
The other problem is that there are only so many minutes in an hour. Time which is spent entering information which is not helpful to patient care detracts from activity which IS helpful to patient care.
A humorous but true story here: When I was an intern a nephrology consultant wrote a note stating something like this: "The patient has a creatinine clearance of 25 and is currently on a nitrofurantoin-containing compound. It has been determined that such compounds, when used in the setting of renal insufficiency, can be associated with a severe and irreversible peripheral neuropathy, and are therefore ill-advised." His partner came along afterwards, scratched out that note, and wrote "NO MACRODANTIN!" in the chart. Who got the point across better?
With the increasing use of EMS, I receive notes from specialists that are 3-4 pages per patient. A full page is dedicated to a ROS. The hospital charts are getting more and more useless. The nurses spend 1-2 hours per patient admission simply asking a set of standard questions to all patients. They have ask a 90 year old female if her Pap/Thin Prep/Mammogram is UTD and test for MRSA by nasal swab on 100% of the inpatients to meet state guidelines. Year round they ask about the flu shots, including on terminal patients. The intake notes take up to 5 pages or more and are rarely reviewed by any doctors.
In a related note, I saw a new, uncontrolled T2DM patient who told me that the 35 minutes I spent with her was more than her last primary doctor had spent with her in the last three years. She never had heard of a monofilament test for sensation on the extremities. Her old records, however, had perfectly dictated notes that were 1-2 pages with 99213-99214 codes on most of the notes with no HGA1C done in over two years. The same doctor is known to have wonderful notes but spends only 2 minutes/patient with the 70+ patients he sees each day. As a final note, most of the handwritten chart notes from my colleagues are close to illegible or are simply check boxes on templated soap notes, which together tell me little about the care of the patient.
One need only look to how surgeons document in their post operative daily notes to understand how much ridiculousness us medical docs are required to document for no other purpose than to get paid and not be accused of fraud. E&M is a disaster.
I totally agree with your post(s) on the documentation diarrhea. It's hard to find solid information in all the crap.
As to the "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." Uh, dear commenter, the ONLY reason an E&M code template is used is for billing. For all other purposes E&M coding is worse than irrelevant since it distorts what we document..
{ 2 trackbacks }