No you make a great point. Except the fact that I peruse the entire chart and I read notes written by all sorts of folks. From medical students to consultants.
The main problem is that folks (non clinical) believe more information documented is better when in fact the opposite is true.
There is a tremendous amount of noise in the chart around the actual meat that is giving you valuable information so you have to spend cognitive load to read nonsense to get to something that is telling you something.
And, I dont know when this started but why are people putting in their assessment and plan at the beginning of a soap note.
It is just so terrible.
epic for anesthesia DOES SUCK.
but so does EPIC IN GENERAL..
That's the fault of the person doing the charting.
Our coding department has been trying (mostly in vain) to explain to doctors that you don't have to actually list the entire PMH/med list/SH in the note to get billing credit.
For example, here's a patient note of mine from Friday:
Family Medicine Progress Note
Urinary Frequency
This is a new problem. The current episode started 1 to 4 weeks ago. The problem occurs every urination. The problem has been gradually worsening. The patient is experiencing no pain. There has been no fever. Associated symptoms include frequency. Pertinent negatives include no chills, discharge, flank pain, hematuria or hesitancy.
Review of Systems
Constitutional: Negative for chills.
Genitourinary: Positive for frequency. Negative for flank pain, hematuria and hesitancy.
Social History reviewed and updated as needed at this visit.
Vitals
Vitals:
10/18/19 1344
BP: (!) 138/87
BP Location: Left arm
Patient Position: Sitting
Pulse: 73
SpO2: 95%
Weight: 109 kg (240 lb)
Height: 5' 6" (1.676 m)
Physical Exam:
Physical Exam
Constitutional:
General: She is not in acute distress.
Appearance: Normal appearance.
HENT:
Head: Normocephalic and atraumatic.
Neurological:
Mental Status: She is alert.
Gait: Gait normal.
Psychiatric:
Mood and Affect: Mood normal.
Behavior: Behavior normal.
Vitals signs reviewed.
1. Polydipsia
- Hemoglobin A1c; Future
- Hemoglobin A1c
2. Type 2 diabetes mellitus without complication, without long-term current use of insulin (CMS/HCC)
New. A1c of 13. Started on insulin today. RTC in 1 week for f/u.
- insulin aspart, niacinamide, (FIASP FLEXTOUCH U-100 INSULIN) 100 unit/mL (3 mL) insulin pen; Inject 15 Units under the skin 3 (three) times a day before meals Dispense: 2 pen; Refill: 0
- pen needle, diabetic (NOVOFINE 30) 30 gauge x 1/3" needle; Use 4 times daily to inject insulin Dispense: 100 each; Refill: 11
- insulin degludec (TRESIBA FLEXTOUCH U-100) 100 unit/mL (3 mL) insulin pen injection pen; Inject 45 Units under the skin nightly Dispense: 1 pen; Refill: 0
- blood-glucose meter (ACCU-CHEK AVIVA PLUS METER) misc; Use to check blood glucose 4 times daily Dispense: 1 each; Refill: 0
- blood glucose test strips (ACCU-CHEK AVIVA PLUS TEST STRP) strip; Use to check blood glucose 4 times daily Dispense: 200 strip; Refill: 11
- lancets (ACCU-CHEK MULTICLIX LANCET) misc; Use to check blood glucose 4 times daily Dispense: 200 each; Refill: 11
- Comprehensive metabolic panel; Future
- Lipid panel; Future
- TSH; Future