The patient note is the biggest problem in medicine today

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Category : Medical Rants

I spent yesterday at Hennepin County Hospital in Minneapolis. During lunch we had a discussion about the thought process of internal medicine, and how we should teach thinking. Not surprisingly, attention turned to the patient note. The teachers in the audience bemoaned the degradation of the patient note.

We need a mission. We need to resuscitate the patient note. We need meaningful, readable, informative patient notes.

A previous rant recently ran on KevinMD – We need to reassess the patient note.

One comment challenged me as an ACP leader to have the organization address this issue.

Without revealing too much, let me assure readers that ACP has made administrative burdens the key policy issue this year.

Our notes have degenerated to satisfy billing requirements. Our EHRs are written primarily to satisfy billing requirements.

We need clinicians (that term used rather than physicians, because not all physicians do enough clinical work to be clinicians) to state the standards for good patient notes. We need real analyses and plans that every other physician can interpret and understand.

We do not need daily physical exams, except for the relevant systems. We do not need daily review of systems, rather just an updated history of the active problems and the answer to the open ended question about new complaints.

We should reclaim the patient note. I would prefer that we return to Larry Weed’s original SOAP notes. Each problem had a subjective, an objective, an assessment and a plan. As I wrote those notes, the pieces congealed into a larger whole. We should unite to object against notes designed for billing. And we should probably outlaw cut and paste.

Comments (5)

I think there should be at least two sections to the note. The first geared to the physicians caring for the patient. The second part full of all the billing info. The second part can ” auto populate” , contain everything the bean counters want and need, and there can be a check box for the physician stating that he actually reviewed the labs, I’s and O’s, vital signs, etc. contained within. I know some physicians will be lazy about truly reviewing the second part, but those that are lazy already are in fact lazy and don’t review my notes anyway. But reams of legal verbage ( eg do you feel abused/ threatened, patient rights rehashed, etc.) and statements such as ” I agree with the xxxx as charted by the RN” are not helpful to me as a physician caring for the patient. I want to know the relevant data ( history/ROS/physical exam findings/images / treatment plans) and thought process pertinent to the reason the patient is here, how the patient is progressing ( better/worse/the same) whether it is in the hospital, office, etc. I don’t need that data/opinion scattered throughout 4 pages of boiler plate as if I am a prospector panning for gold.

Behold the result of the Electronic Medical Record
If the rule you followed brought you to this, of what use was the rule?

Perhaps you could have a daily problem list template that you can cut and paste from note to note but requires an independent entry by the physician such as STABLE , continue current therapy, or UNSTABLE or IMPROVING, etc. and you had to jot a few words/sentences down concerning your plan for therapy or investigation. I think many of us older physician are horrible typists and cut and paste is happening to save time. Where I work just logging on to the computer can take 3 minutes ( and they want you to log on and off because of HIPPA). Even on a bad day it rarely took me 3 minutes to find a chart on the ward. Now seeing 16 patients in the hospital you can spend close to 60 minutes just logging in to the system over the course of a day. That is ridiculous.

There is the physical comfort of the patient to consider, being poked and prodded carries a certain level of discomfort no matter how well meaning.

The other reality is evidence is pointing to even small doses of what appears to be benign drugs can cause some type of mental impairment, add in the drug stew many patients take and you just up this probability. Add in the stress of being in a hospital setting and a doctor may need to focus the patient’s attention, and their time, on the issues at hand.

Steve Lucas

This is a huge problem. You are right on, but overly optomistic thinking that insurers, administrators and data-collectors are going to let us do the something so simple that would improve patient care. A simple, few line note that details the patient’s status and important decisions, thought processes and future plans would allow us to quickly and easily communicate and take care of patients. Instead we document volluminous pages of drivel to get paid. The patient be damned. I hope you start a movement, but am not optimistic.

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