Electronic medical records and detail obsessed doctors

When it comes to writing consult notes, it often seems as if we ID specialists have a blatant form of obsessive-compulsive disorder. Every detail is fair game — travel history, dietary habits, all sorts of seemingly trivial exposures, and of course microbiologic data stretching back to the Cretaceous period.

I’ll never forget receiving sign-out from the graduating first-year ID fellow when I started my fellowship. It included a photocopy of a consult note she had written the day before on a woman with fever after gallbladder surgery.

In five pages of meticulously-detailed prose, there was this memorable item from the Social History:

Two pets at home: a dog (Rusty) and cat (Cleo); both are healthy.

Good news for Rusty and Cleo! But what could this possibly have to do with post-operative fever after gall bladder surgery? Even if you allow that perhaps she was suffering from some bizarre post-cholecystectomy zoonosis (if there is such a thing), why was it necessary to cite the pets’ names?

Electronic medical records have, if anything, made matters even worse for the detail-obsessed. The ability to cut and paste endless reams of data into a note is irresistible to most ID docs.

It leads to a bizarre paradox where the more information in the note, often the less useful it is — a phenomenon expertly dissected over here on KevinMD.com. Says guest writer Jaan Sidorov:

[A doctor] had received a copy of a lengthy consultant-physician’s documentation involving one of his patients and was astonished by the blob of past data, prior notes, test results, excerpts, quotes, interpretations and correspondence that had been replicated word-for-word in the course of “seeing” his patient. The terse portions describing what the patient actually said, what the consulting doctor actually examined and what the diagnosis and plan were were inconspicuously buried toward the end of the EHR document.

And you know what’s most maddening? Under the current “guidelines” for coding and billing, there are true incentives — both financial and regulatory — to write this kind of text-heavy note, one heavily infused with templates and boilerplate language. The more complexity the better!

Here’s a proposal: the goal of a consult note should be concise documentation of what you think, and why, then what you’re recommending, and why.

I’m sure Rusty and Cleo would agree.

Paul Sax is the Clinical Director of Infectious Diseases at Brigham and Women’s Hospital. His blog HIV and ID Observations, is part of Journal Watch, where he is Editor of Journal Watch AIDS Clinical Care.

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  • http://drpullen.com Edward Pullen MD

    All this is true. See a prior post on the APSO note. Put all the verbiage you want in the note, just to give us primary docs a break put your assessment and plan at the top.

  • http://afmarcom.com Angelique

    You know what’s worse? Reading a ton of notes a doc or nurse took and the details are WRONG. Were they even listening?

    • BladeDoc

      Silly Angelique, Medicare doesn’t care if the details are correct, they don’t care if you get good medical care (at least if it’s cheaper), they pay for the documentation. Remember the payer is the customer, you (the patient) are the PRODUCT.

  • LynnB

    My office notes are just like the Rusty and Cleo note…Last kid in college, what can I say . I’m spending the time, I need to pay tuition.

    When I do a consult I put the plan in bold . You probably have much better editing than in our off the shelf Rubik’s cube of a product. The irrelevant filler that insurance seems to like (since each note stands alone) I sometimes even put into small type. Stuff like Rusty’s breed -I understand Labradors are less like to sicken their owners after GB surgery than Newfoundlands.
    ………………………………………….
    I just got dinged for not documenting enough “systems” or “body areas” on physical exam on a pregnant type 2 diabetic . So I documented on the abdomen area of the EMR “large” . It flies, along with the things that are actually relevant and and brings me up a coding level.

  • Marc Gorayeb, MD

    Shock and disbelief that the system would encourage such behavior.
    Denial that you would ever succumb to the required adaptive behavior.
    Bargaining with the bureaucrats, expecting them to see the irrationality of the system’s rules.
    Guilt that your non-involvement may have allowed others to regulate your life to the point of complete distraction.
    Anger that you are essentially being forced to behave in a way that will short-change your patients’ care, impoverish you, and serve the system’s primary goal of total obediance and compliance.
    Depressed that you appear to have no power to affect positive change at this point.
    Acceptance of the tidal wave of bureaucratic oppression, and Hope that someone else will eventually come along and save you.

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