We need to reassess the patient note


I recently tweeted about Danielle Ofri’s important piece, The Doctor Will See Your Electronic Medical Record Now.  I like the piece, and especially like some of the quotes, but still I believe the problem needs an expanded take.

Context represents the major advantage of 38 years experience as a physician.  Over time, one sees trends come and go.  Hopefully one can see the strengths of the “good old days” and yet recognize progress.

Most physicians love medicine the most when we are with our patients.  We like talking with patients, examining patients, and trying to help patients.  We do not like charting.  We dislike filling in meaningless data just to meet billing requirements.  We hate reading computer generated notes; notes generated to satisfy Medicare, Blue Cross/Blue Shield, etc.  We like getting it right.  We hate forms.

When I started, most private physician notes were undecipherable.  Most resident notes actually were helpful.  We learned to write SOAP notes, and often you could actually understand what your colleague was thinking.

Along came the resource-based relative value scale (RBRVS) and notes began to deteriorate.  We started having coding workshops, learning the components of a billable note.  The notes began to deteriorate again.  Then came electronic medical records to save us.  They guide us through the note, demanding all the information to allow a level 4 or 5 billing.  But high billing codes do not require sensical notes.  Our notes had more “stuff,” rather more “fluff,” but less meaning.

Electronic health records are a great idea, poorly executed.  Too often they are more about billing than communication.  Too often physicians use checklists rather than free text, because checklists are quick and free text is slow, because we can do easy data analysis on checklists, but not on free text, because checklists allow us to bill higher and we get paid more.

We need to reassess the patient note.  The patient note should have nothing to do with billing, rather it should focus on communication with other professionals and reminders to ourselves about how we thought about the patient when the note was written.  The note should be informative.

Physicians should spend more time with patients and less time with computers.  Physicians should spend adequate time with each patient rather than rushing through visits to improve their RVUs.

Dammit, we are not making widgets.  Patient care takes as long as patient care takes.  Some patients need short visits and some need long visits.  Most do not need a 12 point review of systems or a full physical exam documented.  When I see a patient in the hospital with pneumonia who is improving, why should I examine the oral cavity again, or even the abdomen again (assuming no new symptoms).  I should listen to the lungs, assess the work of breathing, review the vital signs and assess the patient’s progress. I should consider every day the possibility of discharge.

I should care for the patient. Caring for the computer does not compare.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.


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