If you are right, then they don’t know what they are doing–and if they don’t what they are doing, who is going to save us!

Old timey records were made to summarize the doctor’s thinking at the time of a visit and a note of the plan.

Then medicolegal necessity required longer and more complete documentation, something that would stand up in a courtroom as a demonstration of a rational and reasonably complete clinical assessment and treatment paln.

Now we are in the age of the EMR and the driving force behind the grotesquely overwording is the CPT guideline for Evaluation and Management coding. EMRs aren’t about making records that make sense for some other doctor, or about establishing useful databases for remote access or to create a comprehensive patient record to avoid unnecessary over-testing or drug interactions. They are made to create records that will pass Medicare audits.

All you have to do is follow the money.