Isn’t it time we began embracing the simplified documentation guidelines that finally came about to ease our billing and coding woes?
These pared-down Centers for Medicare & Medicaid Services guidelines, put into place now nearly 3 years ago, were designed to help minimize note bloat, to try and cut through all the stuff that made our medical records essentially useless behemoths of documentation. Notes that go on for page after page, endless reams of data and templated macros that someone thought were going to make our lives, and by extension the lives of our patients, better.
The amount of work and energy that we all put into creating these things unfortunately seems to far surpass the mental energy we are ultimately able to put into taking care of our patients.
We’ve let ourselves go down a pathway of charting electronic medical records that put a focus on what is written on the page, instead of our actual thought processes and documentation of what really happened that day.
I recently saw an example of how “simple” a note could be, posted by one of the medical societies.
It was demonstrating how, in order to reach a moderate level of complexity for billing, all we really needed to document for managing two medical problems was a brief set of statements indicating that the patient was here today for management of those conditions, was having no issues with taking their medicines, and that we were planning to continue those medications.
For example, documentation of an office visit for the management of well-controlled hypertension might read: patient is taking their medicines, notes no side effects, has no referable symptoms, and the medication is going to be continued, maybe along with home blood pressure monitoring, maybe some relevant lab testing, maybe some patient education.
We should be able to accomplish this in just a few lines.
When was the last time you read a consultation note from a subspecialist that really just got to the point?
Why do we need to see, in every single office note, every single past event that occurred for the patient that might in some way be related to their condition?
Oncology patients who arrive for a dose of chemotherapy don’t need to have their entire charts re-dictated, or re-cut and pasted, into today’s note.
I know that the subspecialists like to see the long trail of events that led to where we are today, but often at the end of their voluminous notes we come to the two lines that are relevant — all that matters.
Here today for follow-up of their cancer, mild side effects from the last dose of chemotherapy, now improved, ready for dose number four, check CBC and electrolytes today, CT scan in 3 months.
And how many times have you seen a urologist’s note containing an incredibly vast review of systems and physical exams that includes every single organ system, including HEENT, heart, lungs, abdomen, and psychiatric?
Do we really need their judgment, mood, and insight? Alert and oriented × 3?
All we really want to see is what they thought of the patient’s urologic exam.
True, there are certainly times where they should be thinking about things more broadly, when the abdominal exam might make some sense for the urologist, but more often than not, a cardiovascular and pulmonary exam isn’t really why I sent the patient to see them.
I thought their prostate felt abnormal, you?
Much of this could be answered with a few simple lines, and we’d all be much better off — both the producers of this excessive documentation, and those of us required and expected to read it — if we could just cut to the chase.
In 1862, Victor Hugo reportedly wrote the world’s shortest letter to his publisher, inquiring how sales of his latest book were going.
His publisher replied “!”
This is something we should all aspire to.
When I was an intern, rotating through subspecialty services in the hospital, the attendings would require us to hand write the entirety of the patient’s previously dictated discharge summary into our admission notes.
And then when the patient was discharged from that hospitalization, the attending would require us to dictate the entire course of the hospitalization, including all tests, procedures, and treatments, and add this on to another dictated version of the entire previous dictated discharge summary.
Bloat piling upon bloat.
Perhaps as our electronic medical records continue to get more sophisticated, continue to be more flexible, and continue to receive our input, we will find a way to put this excessive information into a separate repository, a place where the detailed true past medical history, the true hospital course, the true course of a specific illness, can be plotted and mapped and managed and maintained.
Keep the notes from today relevant to what’s happening today, what your patient came in for, what was discussed, what you thought about what you found, and what you plan to do about it.
Why do we need to cut-and-paste every lab, every procedure result, every imaging test report, into every day’s note during a hospital stay or an outpatient evaluation?
Certainly we can reference it, bring in the important points, use the functionality of the system to track trends, but repeating data over and over again just creates noise that buries the signal, the true signal of clinical care.
Finally, after years of complaining, the bureaucrats in Washington listened to us and removed the requirements for vast past medical/social/family histories, detailed reviews of systems, multiorgan physical examinations, and agreed to let us just put down the meat of the matter.
Like many things in healthcare, we’ve been moving slowly to adapt, unwilling to change, reluctant to give up our massive notes.
Perhaps there was a sense of, the longer the note, the greater the importance of what we were doing for the patient.
But we can all recognize the truth of the matter, that it’s all there in a nutshell.
Cancer responding, continue current chemotherapy, recheck labs.
Continue current blood pressure medication, work on diet and exercise.
Prostate exam abnormal, recommend MRI and biopsy.
Isn’t it time we got to the point?