Comments on: Documentation – a harsh comment

By: E&M Guidelines Undermine Patient Care - Healthcare Rationing and E&M Guidelines

Mon, 12 Jul 2010 11:23:30 +0000

[...] exceedingly polite objection is not to be countenanced. One of DB’s correspondents fired back at him: “The templates are there to serve as a guide, not a hinderance. If you don’t like your [...]

By: Hal Dall, MD

Hal Dall, MD — Mon, 05 Jul 2010 23:00:14 +0000

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..

By: The Happy Hospitalist

The Happy Hospitalist — Sun, 04 Jul 2010 13:40:36 +0000

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.

By: solo dr

solo dr — Sat, 03 Jul 2010 12:21:13 +0000

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.

By: Tweets that mention Documentation – a harsh comment — db's Medical Rants -- Topsy.com

Sat, 03 Jul 2010 04:17:10 +0000

[...] This post was mentioned on Twitter by Robert Centor. Robert Centor said: Documentation – a harsh comment – http://bit.ly/bdBCxx by @medrants [...]

By: Dave

Dave — Sat, 03 Jul 2010 00:56:47 +0000

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?

By: cory

cory — Fri, 02 Jul 2010 22:34:39 +0000

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.