I attended part of a workshop on hand-offs yesterday. The workshop was excellent, but made my think about root causes. One of the speakers focused on making your rationale explicit during hand-offs, e.g., check the BMP – the creatinine is 2.0 and we expect it to decrease. If it increases then do …
This information used to be in the chart. We were taught to write informative notes that included our reasoned assessment of the current situation and our explicit plans related to that assessment.
Too often I do not see such notes in 2009. The notes take as long to write, but are dominated by billing requirements. We see review of systems and physical exam repeated everyday, even when this recording is a clear waste of paper.
We have a significant degradation of notes to meet bean counter requirements. I know of no physician who thinks that the new notes are necessary for patient care. I submit that a clear explication of assessment and plans would make transfer of information much easier than the notes I read today.
This represents just another intrusion of Medicare and the insurance companies. Of course no one will address such issues in the health care reform debate. Could the degradation of our notes present a patient care risk?
