Notes in the chart are helping patients less

What is the purpose of the note in the patient chart?

Depends who you’re asking.

The best guidance I ever received on how to write a good note came from my residency program director, who told us that a note needn’t be encyclopedic to be excellent; in fact, he urged us to get away from the “second-year medical student” style, which typically includes absolutely everything.

Instead, he urged us to write, as concisely as possible, notes that included the following:

  1. What is going on with the patient
  2. Why we think so
  3. What we’re going to do about it

All this gets thrown on its head, however, when you get an e-mail like this one:

Hello Dr. Sax,
Just a reminder that I will be meeting with you to discuss your billing audit results on Thursday 5:30 pm, right after your outpatient session is completed.

In this meeting, I predict Judy will tell me that the occasional visit I coded as “Level 5″ really should have been “Level 4,” or even “Level 3″ — since even though the case was incredibly complicated and involved reviewing years of treatment history, lab results, and prolonged communication with outside providers and the patient and his family members, I somehow neglected to include the requisite number of “Review of Systems” (10 required), with explicit mention of past, family, and social history, as well as a 9-system physical exam.

Oh, and the sentence:  “Time spent reviewing impression and plan with patient and family:  — minutes.”

Yes, abuses by MDs and hospitals on billing have been well documented.  Cases like this one are obviously serious, and cannot be condoned.  It could be argued that these periodic “compliance reviews” (my session this week with Judy) are merely the just rewards of a previously unpoliced system.

But does anyone think that the current rules we have in place — with these explicit guidelines for what constitutes a complex case based on who knows what (”Review of Systems?”  c’mon!) — is anything other than an invitation to game the system with fancy software, macros, templates, lots of copy-and-paste, and other such tricks?

And what happened to what should be the primary purpose of the note — which is to communicate the critical items of the medical encounter?

That’s the saddest part — it’s gone.

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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  • Susan

    Number 3: the future of diagnostic/treatment/discharge is most important and sadly often ignored.

  • The Scrivener

    Well put. My med school’s hospital now require all outpatient encounters to be documented with an electronic form full of checkboxes, instead of with free text notes. This makes billing easier for the administrators, but the auto-produced notes are impossible to read: the pertinent findings are swamped in an all-caps sea of NORMALs. As the student, I still have the luxury of free-texting my notes — it’s faster, simpler, and actually gets the point across. But the residents spend more time checking off boxes than actually examining patients. It’s actually a big turnoff when I think about making my rank list.

  • Medical Contrarian
  • anonymous

    Well said, Dr. Sax.
    When I started my practice, I realized the only way I could find something quickly in my own patients’ charts was to insert a running list of problems and results I wanted to remember. Recently, a nurse doing a site visit for my malpractice carrier told me that sheet did not fit standard chart documentation requirements. Unfortunately for me, my argument that this sheet was just my own little crib sheet, that everything contained on this piece of paper could also be found in more detail elsewhere in the chart, fell on deaf ears. I will have to change my documentation practice, and this piece of paper will probably no longer be useful to me. Any suggestions on how we can make the chart helpful to patients again?

    • stargirl65

      I would label your running cheat sheet a Health Summary page. This meets most insurers definition of what something is and also fills in requirements for PCMH requirements.

  • Chris

    And even though I loved CPOE at Kaiser the Sea of Checkbox billing notes is atrocious. Nice thing about a radiology residency isI still can dictate my reports.

    • Paul Dorio

      Ha! Only until you are “switched over” to the voice recognition systems that result in markedly reduced transcription costs. I’ve adapted and acquired a new way of dictating, but I’ll tell you, it is remarkable how much you regiment yourself to keep up efficiency.

      I “joke” that I only actually do 15% real diagnostic radiology during the reading of each study, with the other 85% being mostly cut, paste and bureaucratic activities. (Luckily, I get to break up my radiology with actual direct patient care, as I am also an interventionalist!)

  • Sharon MD

    Agreed. The computer-generated notes are full of garbage and require a lot of effort to find the useful information. We have recently transitioned to EMR and I find myself spending a lot of time erasing things that don’t need to be in the note. I have to manually remove all the short-term medications I’ve prescribed (ie cough medicine, a short course of antibiotics, etc) or they overwhelm the medicines that are actually important. We also have to connect everything to a diagnosis, so the problem list is full of useless information like “viral exanthem” and “upper respiratory infection” and “preventive health care”. Of course hidden among all this BS are the important things like diabetes, heart disease, etc. The names for problems are also ridiculous, like “acquired absence of uterus” (our EMR’s version of hysterectomy)

    I personally free-text most of my notes and don’t use the check boxes generally because they generate a lot of garbage. The physical exam is also ridiculous; by clicking “normal” for the eye exam, for instance, you get the normal results of a 2nd year med student exam that takes 10 minute (fundi, sclera, confrontation, all the things we only do in certain situations)

    Fortunately where I work most of our patients are in capitated Medicaid plans so the number of points on ROS I tick off isn’t very important. But really, having to ask about if someone has a cough when someone presents with depression in order to get appropriately paid for your time is just ridiculous.

  • Kathy Wire

    A wise person (not me) has said that we chafe about medical records because they try to serve two purposes. The first is a very linear record-keeping purpose, for billing and QA. The second is the healthcare professionals’ investigative process as they care for the patient, generally non-linear. I think we will do better if we recognize both and incorporate aspects of record-keeping to support them. I work in risk management, where we need both the “what happened” and “what was I thinking” portions. Unfortunately, they rarely appeared together. A few gifted physicians created great notes. It was an art.

  • David Voran

    Nearly 3 years into using structured documentation tools I’m seen a gradual evolution that’s increasing the signal to noise level. In the past one click would bring in a complete family history from the record that would take up the whole screen and half a printed page in the note. It’s now replaced by a single line macro that states “Family, Medical and Social History reviewed with patient.” This meets the coder’s needs and they know we do this because we construct the note in front of the patient during the exams with both the patient and the providers sharing a screen.
    In addition now over 50% of my notes include pictures (all rashes, lesions, interesting physical findings like purpura, swollen joints, etc.). The inclusion of pictures dramatically lowers the unnecessarily detailed and often incorrect terminology.
    The whole process reminds me of how people discovered e-mail or word processors. Remember when people would spew out jokes and junk just because it was so easy to do? Or use all of the fonts and features just because they could? Mature users of these tools eventually find their way back to the signal and begin to ditch the noise.
    I’m thinking the same thing is true about our notes. Concentrate on the signal and reference the noise (since it’s all available). It has passed muster with our coders who I often think are an arm of the CMS rather than making sure we’re maximizing our charges.
    It’s interesting that they are asking us to spend more time on the medical decision making part of the notes as that’s where the meat of the process is rather than on the routine stuff that’s pulled in.
    With electronic systems it is easy to document a 99215 for a sore throat visit that took 5 minutes. Just because you can do it doesn’t make it right. By the same token, simple documentation of your thought process and what’s been reviewed can justify the 99215 without making a lengthy, detailed note.

  • Skeptical Scalpel

    I agree that computer generated notes are garbage. A place I used to work at had a system that allowed for copying and pasting. This led to some interesting stuff like “The patient underwent a tracheostomy yesterday” appearing on the chart for two consecutive days.

  • Dr. Pi


  • stargirl65

    Notes are now designed for insurers, lawyers, coders, payers, etc. They are not designed for the patient or the doctor.

  • richard scott

    I could not agree more with the note. I found many rounders cutting and pasting notes and lab values on their “progress note” …not the reason for a note.

  • Adam

    I always find it amazing to think that we have to put in specific and usually unrelated and unnecessary data to meet the current guidelines in order to be able to bill a specific code such as a 99215 or 99214. We do the work but if our note just is not up to current guidelines, then we can’t get paid for that work. I too can turn a 5 minute cold into a documented 99215, but remember that “medical necessity” is the driving force for the documentation and that, according to the experts, should be your guiding light for the visit with regards to the proper coding in relationship to the documentation.

  • e-Patient Dave

    All the more reason to ditch insurance companies, one way or another.

    Whatever the virtues of insurance, I keep running into insane, contorted, perverse consequences of its existence. And they all boil down to getting in the way of patients and physicians doing care the way they want to!

    And I can’t help but wonder why, when I discovered many gross errors in my insurance records a couple of years ago and blogged about it, nobody contacted me to say “Can we go through and audit your record?” Is this industry a mismanaged mess, or what? Heaven knows they’re costly.

    (I’m happy to be corrected on any of this. My own insurance company, Harvard Pilgrim Healthcare at the time, was fabulous during my illness – I have no personal complaint. But I’m very unhappy about the many many stories I hear of docs being interfered with, not to mention patients who (unlike me) are told they can’t have the care they need.)

  • DCPharm

    As a patient that has been reviewing my notes recently for insurance purposes, I am amazed at the inaccuracies. Things I say that I think are relevant that aren’t mentioned. And the mention of irrelevant things! Then there is the doctor that dictates his notes 3 weeks after my visit & must not be able to read his own writing because he gets it all wrong.

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