The X-Files fans will remember the poster that Agent Mulder had on his bulletin board with a picture of a flying saucer and the words, “I want to believe.” That’s how I feel reading EMR notes sometimes. I want to believe, but I doubt.
I know how this happens. The EMR vendor, the practice implementation team and the doctor have a meeting to develop the “normal” template for a hospital admission or a diabetes follow up visit. I myself may have participated in these meetings. Let’s use the admission as an example. We want to develop a template with a comprehensive exam, so that it will meet the requirements for a level two or three admissions. The coding specialist hastens to add that not all admissions are high level admissions, but if the admission is complex, we don’t want it to down code based on missing one exam element. The template is done, and the doctor never looks at again. The doctor never reads, line by line, the admission note that s/he generates using the “normal” exam template.
- 86-year old woman admitted with a small bowel obstruction with “gait—non-antalgic.” Really? The doctor had the patient get up off the gurney in the ED and walk?
- Normal external ears for a non-ear problem. I know: it’s a bullet on the 1997 exam, but have you ever documented it before? Don’t do it unless it’s relevant.
- A toddler with normal insight and judgment. My toddlers didn’t exhibit insight and judgment, but maybe they were backward.
- A seven month old seen in follow up for otitis, who has no carotid bruit or JVP.
- Abdominal exam normal, “with normal surgical scars, if any, as described in history.”
- The same exam for all problems. I mean, the exact same exam for all problems.
The same difficulty occurs in the ROS, using a “normal” ROS exam. Use caution with the use of these normal templates. In the history section, contradictions in the HPI and ROS are particularly troublesome. For follow up visits, you don’t need a complete ROS except for a 99215. 99213 requires only one system in the ROS and 99214 requires only two systems in the ROS.
What to do? How to make the best use of EMR, take advantage of their time saving features (I know, almost an oxymoron, but there must be some—I want to believe) and not produce cookie cutter notes? Here’s my advice: document what you would have documented when you dictated records. Don’t do a complete ROS for every follow up patient. Print out and read line-by-line a sampling of your own notes. Have different exam templates for different problems.
Your history of the present illness should have more characters than a tweet and contain at least as much information. If it is too difficult to free text what brought the patient to the visit and to describe the symptoms, insist on dictating that crucial information into the record.
Physicians sometimes blame us for their EMRs. “You made us use these systems.” “Health information tells me that has to be in the note for meaningful use.” Health information won’t be responsible for the repayment if a payer comes calling. No one in health information has a provider number: the clinician’s provider number is on the claim form. Take responsibility for both the information and the format and insist on a format that makes clinical sense.