Brevity is the soul of a good EMR note

Shakespeare said that brevity is the soul of wit. I say brevity is the soul of a good note.

As a resident back in the early 90s I would look at office notes written by older, near-retiring physicians. I’d read these one or two lines written on 3 1/2-inch note cards, turn to my fellow residents and ask, “How can someone possibly document this way?” Years later, I realize the genius, beauty and efficiency of this type of record, and it seems I’m not the only one. There is a crisis in medicine and, in many cases, the introduction of electronic health records (EHRs) has made it worse. Providers have too much to read at the end of the day, much of it adding little value to the care of our patients.

My health records from my own pediatrician, Dr. Patrick Brucoli (who continues to be an inspiration), span nine years and about ten visits, with a total page count of less than two. Granted, I was a relatively healthy kid … but recording ten visits in just 1 3/4 pages? That’s unheard of today. When I have a new patient that has transferred from elsewhere — and in particular, when an EHR is involved, I groan. The amount of time and concentration it takes to get through that chart, and its pages and pages of verbal diarrhea is daunting. The endless nonrelevant review of symptoms (ROS), family, social, enviromental, extensively documented physical, etc. disguises the essential information that is buried within. It is amazing how much of today’s documentation is clearly just automated jibber-jabber.

I compare this to my childhood chart from the 1970s, Dr. Brucoli taking notes in which every word matters. I can truly review the pertinent aspects of the chart in just a fraction of the time that it takes to understand the record from one of my own incoming patients. The beauty is in the brevity, in how clearly those shorter notes communicate what a visit was about. There is much less chance that something will get lost in the weeds of minutia.

Today, in any correspondence I receive from a physician, I trust that he or she has done a comprehensive history and ROS, has asked about smokers in the house and did the appropriate anticipatory guidance. I don’t need to read about it; this is only a distraction and I would contend that it’s potentially detrimental to the care of the patient. We are overloading physicians with reams of notes that are important — but not at all relevant when trying to communicate the crux of a visit. If within the three-page emergency department discharge summary, nestled in the extensively documented physical exam, you mention that you heard a concerning murmur, that finding shouldn’t get the same press as a “chest: clear to auscultation and percussion, no rhonchi rales or wheeze, no increased respiratory effort, and no grunting flaring or retractions.”

I realize that at this point you may be thinking, “Well, there is stuff that needs to be asked, screened and documented.” And I agree. Clearly our roles in health care have changed based on regulations and mandates, and what we need to discuss with patients has changed along with it. We now screen for mental health issues, domestic violence, substance abuse and home/life safety issues, all of which are important. And insurance companies are auditing charts with a closer eye than ever, looking for everything that was covered during the patient exam to justify what was billed. And while I realize I’m a bit of a hypocrite in what I’m about to say, this is exactly where we need to take advantage of electronic health record technology. When an EHR really works, we have the ability to produce both a brief note and a full patient record. Note the emphasis on really.

With a significant part of our job relying on the communication we receive from fellow physicians, we need the ability to easily produce a lean, readable document that communicates three things: 1) what the doctor believes to be the diagnosis, 2) how he/she came to that conclusion and 3) what we are going to do about it. (Sounds a lot like a 3 1/2-inch note card.) Then, in a separate section of the EHR would be all the information that is, essentially, irrelevant for me, but can be made accessible for those requiring the minutia, e.g. insurance companies, lawyers, etc.

So, while we don’t have an option to turn a blind eye to the adoption of electronic records, we can, and should, demand from ourselves and all in our referral networks to produce clear concise communication. And we should continue to push on our EHR vendors for this ability. Let us hold onto the simplicity and clarity — the soul — that a 3 1/2-inch note card gave us.

Scott Moore is a pediatrician and blogs at the athenahealth CloudView Blog, where this article originally appeared.

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  • Skeptical Scalpel

    As long as the coding and billing are linked to the documentation, you will never see a concise note again. It is impossible to find anything important in today’s electronic hospital records. The same ROS’s, social hx’s etc are repeated over and over until the chart becomes useless. Don’t forget the pages and pages of nursing check boxes too. I think the situation is hopeless.

    • buzzkillerjsmith

      Amen. The local ENT gives me 4 pages for a packed nosebleed. His template asks whether the patient has a family history of depression and seizures.

      • NewMexicoRam

        LOL! The specialists in our group just use the FH/SH/PMH that was typed in by we PCP’s! Quick and easy!

  • Greg Hinson

    I know a doc that was fired by his hospital overlords for brevity. Couldn’t agree more. But, brevity implies lack of complexity which means leaving money on the table which means less money available to pay the salaries of hospital administrators.

    • John C. Key MD

      Wasn’t me but I catch heck for it all the time. My boss likes lots of boilerplate pasted in. Worthless.

  • RuralEMdoc

    I totally agree with everything the author just wrote. If I were to copy and paste the text, and then pass it off as my own, that would be plagiarism. Good thing no such problem exists with EMR notes, otherwise they might never get done with all the nonsense that is required to go into them.

  • John C. Key MD

    Time to man up, guys. Force the return of the succinct note.

    • T H

      Even a complex patient can be economized in a simple declarative statement: “Mr. S is a 78 year old with a history of stable angina following 4 vessel CABG with DM, HTN, and CRF on warfarin for a. fib presents with melenic stools for 3 days.”

      You know the problem, you know the most likely reason why, and can think about potential complications after <40 words that takes 10 seconds to relay.

      • Acountrydoctorwrites

        Nice narrative, but not structured data entry, now, is it?

  • buzzkillerjsmith

    Notes don’t cure patients. Orders cure patients.

  • PoliticallyIncorrectMD

    The major reason for long useless notes is billing, not fear of litigation. Physicians are payed according to how much garbage is In the note, nothing else matters. Very sad : (

    • NewMexicoRam

      They both helped to cause this mess. I just focused on the one aspect of malpractice.

    • Acountrydoctorwrites

      The longer you take to make the diagnosis, the more you can charge…

  • Scott Moore,MD

    There is no doubt that the EHR has to some degree gotten us into this situation but I do feel it can be part of the solution. We should be able to document to our hearts content to support what is being billed/coded. The EHR should be able to blind much of this pointless documentation to the clinical reader. I am assuming that the provider has reviewed the ROS/Family Hx/Social Hx….. and will include pertinent information in their final Assessment and Plan. Instead all of that stuff keeps being pushed downstream for every reader to process. This is a colossal waste of time. It would be refreshing if more notes/dc summaries/office notes plainly said what the doc was thinking was going on and what she proposed to do about it. We as providers are to blame in this as well–it is easier to keep pushing all this data downstream instead of creating a concise readable note.

    • http://bioethicsdiscussion.blogspot.com Maurice Bernstein, MD

      Scott, there is one problem not discussed here regarding brief “summaries” of a patient’s medical history and physical examination. That problem is the heuristic thinking errors which can occur when another physician (or even the writing physician) attempts to evaluate or revise the conclusions raised in the document. For example, the heuristic of “anchoring”: focusing
      on vivid, salient features in a clinical presentation in the process of establishing or confirming a diagnosis. The brief presentation oriented to the conclusion of the writer with the writer’s rationales may impress the reader with a diagnosis but the true diagnosis may be missed since only the writer’s selected facts are presented and the other perhaps more diagnostically significant facts are not readily available.

      What is best is a well documented complete history and physical and so formatted that a reader can move through it systematically finding the facts necessary to create the reader’s own conclusions. And it takes a reader who is willing to take the time to read and think.

      I worry that EMR is making the potential for heuristic thinking errors more likely by categorization and summarization that is required. ..Maurice.

  • DeceasedMD1

    what i ponder is how many pts have died from bad ehr notes. sorry for the sarcasm but any pt with complex problems in corp med no doubt has increased morbidity and mortality since in Epic land no one actually collaborates terribly effectively

  • Docsicle

    Perhaps an EMR could be designed by docs, rather than programmers? I’d prefer an EMR that tracks all the extraneous socio-environmental stuff (SHx, FHx, etc.) in a separate section that does not show up in each note, but still readily accessible to the physician. Make an EMR with a true SOAP note, but that may still be used for accurate billing. With all that medicine has accomplished, you’d think we could get this done!