DB'S MEDICAL RANTS

Internal medicine, American health care, and especially medical education

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Thoughts on documentation

When you write a medical blog as long as I have, you often resurrect topics.  Many readers are new, and even long time readers probably will not complain.

I believe that documentation requirements are harmful to medical care and education.  They represent the worst of bureaucratic committee decision making.

Let me expound on the evils.

  1. Documentation requirements encourage recording of both history and physical “points” rather than a well stated and summarized history of present illness.
  2. Documentation requirements therefore make such recording rote and too often we do not focus on the very necessary parts of the exam.
  3. Documentation requirements do not reward us for a careful exposition of our thought process, yet that recording would trump the 8 system history and 8 system physical exam.  We need other physicians to know what we are thinking (and why).  We need to make our plans clear.
  4. The problem becomes accentuated with the cut and paste feature of many electronic records.  My automatic notes at the VA start with about a page and a half of automatically introduced data.  I try to share my thoughts in the appropriate spot – but who ever gets to that part of my note.
  5. Buffing the chart becomes an art form, but does it have anything to do with providing excellent patient care.  I posit that focusing on the chart (and avoiding a bad audit) takes attention from the patient.
  6. Our documentation requirements substitute from something much more important – a careful reasoned approach to the patient and his/her problems.

Once upon a time, the chief residents taught us to write SOAP notes.  My SOAP notes were easy to decipher.  I included the issues that I thought were important and my assessments were always clear.

Too many suits focus on documentation requirements rather than teaching.  Ward attendings once focused on medical education, now too often they worry about the chart and billing.  They have this worry because their boss has this worry.  The suits talk about documentation; they pay for documentation courses; they order mock audits.  The suits rarely talk about teaching.  The implicit message is loud.  Ward attendings should prioritize documentation and billing rather than education.

Many attending physicians remain committed to medical education.  Unfortunately too many put their energies into billing rather than teaching and thinking.  The charts are technically perfect, but too excellent clinicians they are sterile and uninformative.

Medicare has been a great program since its inception, but it has created negative externalities.  Our strict documentation codes have no rational basis.  Only a bureaucracy could produce this paperwork travesty.

Time for db to step off his soapbox.  I hope this rant resonates with some readers.  I do not have a solution, but typing this complaint was easy and perhaps we can start a movement.

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