How do you impress referring physicians with note?

[DrMDAware]

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Hey,

What are some practical recommendations you have to write a quality note that impresses the referring physicians?

Look, I get it that time is money and we can't be writing a novella.

However, we've all seen the notes where the dot phrases don't pull in any information. Or the ones with a deluge of information no one really cares about.

I imagine these are easy to do with preformed dot phrases and Dragon Speak shortcuts.

Some things I had in mind...

• include some (but not too many) references
• include mentioning a Plan B and C if Plan A doesn't work
• making it very easy to find the plan (put it at the top or put it in a different colour)
• include some discussion of a differential
• include a narrative and not just bullet points (controversial)
• A link that automatically contacts you (ie webpaging or email)

Bonus points if someone includes a rough outline/template they use.

 

[painfree23]

Hey,

What are some practical recommendations you have to write a quality note that impresses the referring physicians?

Look, I get it that time is money and we can't be writing a novella.

However, we've all seen the notes where the dot phrases don't pull in any information. Or the ones with a deluge of information no one really cares about.

I imagine these are easy to do with preformed dot phrases and Dragon Speak shortcuts.

Some things I had in mind...

• include some (but not too many) references
• include mentioning a Plan B and C if Plan A doesn't work
• making it very easy to find the plan (put it at the top or put it in a different colour)
• include some discussion of a differential
• include a narrative and not just bullet points (controversial)
• A link that automatically contacts you (ie webpaging or email)

Bonus points if someone includes a rough outline/template they use.

Ew, seriously? I think a differential is fair but everything else is too much. Color coded notes?! What the heck

 

[Ligament]

I used to work really hard to provide useful notes for referring docs. Did this for many years.

After many years, I realized nobody read these notes except patients or lawyers. No referring docs ever called me to discuss, even though I'd put my contact number in a cover letter as well as direct email.

Therefore I advise you don't waste your time. Make your note useful to yourself for future care of your patient, protect yourself against lawyers, and to score insurance "points" so you get your care plan approved. Thats it.

 

[VA Hopeful Dr]

I used to work really hard to provide useful notes for referring docs. Did this for many years.

After many years, I realized nobody read these notes except patients or lawyers. No referring docs ever called me to discuss, even though I'd put my contact number in a cover letter as well as direct email.

Therefore I advise you don't waste your time. Make your note useful to yourself for future care of your patient, protect yourself against lawyers, and to score insurance "points" so you get your care plan approved. Thats it.

Yep. I can't speak for all your other referral sources but us PCPs don't really care beyond the basics of: what do you think is going on and what are you doing about it.

 

[Nodolor]

Referring docs don't have time or want to read your note. You really think they are going to look up references and citations? Their main concern is that you deal with the patients "pain".
Sum up your plan in 2 short sentences at end of your note.
Will make your life easier.

 

[Agast]

Make the assessment and plan easy to read. Referring docs will sometimes glance at the notes. Some of these EMR-generated notes are monstrosities, I’ll get outside pain records and each note says the exact same thing and I have no idea what was actually done or planned that day.

I started getting referrals from a PCP I’ve never talked to, he’s gotten automatic notes from me because my EMR lets me send an efax once we know who your PCP is. My new patient told me I was highly recommended by their PCP. I’m in a pain-saturated area so the only thing I can think of that sets me apart is that you can follow my notes.

The A/P is always:

One line summary about their issue and what I think is going on plus any important nuggets (pending cancer work up, about to have knee replacement, etc)

Then the following template

1. Medications:
2. Studies:
3. Procedures:
4. Rehabilitation:
5. Psychology:
6. Referrals:
7. Follow up:

It makes it a lot easier for me to track what I’m doing with a patient, or to refresh myself for someone I haven’t seen in 3 years. And my staff can follow it too and answer phone calls based on the info. Now it’s helpful for complexity billing as well.

 

[Baron Samedi]

The length of your note is inversely proportional to the amount of information another provider will extract from it.

 

[DrMDAware]

Ew, seriously? I think a differential is fair but everything else is too much. Color coded notes?! What the heck

The idea would be to make it easier for someone reading the note to find the A&P easily. That way they wouldn't be wasting their time wading through BS. And only the header of "A&P" would be in red, for example.

Therefore I advise you don't waste your time. Make your note useful to yourself for future care of your patient, protect yourself against lawyers, and to score insurance "points" so you get your care plan approved. Thats it.

Point taken.

Referring docs don't have time or want to read your note. You really think they are going to look up references and citations? Their main concern is that you deal with the patients "pain".
Sum up your plan in 2 short sentences at end of your note.
Will make your life easier.

The idea for references would be to show them my recommendations are evidence based. I'm hoping to do whatever I can to push back against the tide of non-pain boarded 'pain specialists', people running pill mills, people practicing outdated medicine etc.

The length of your note is inversely proportional to the amount of information another provider will extract from it.

Right. That is why I said I don't want to write a novella. Something concise is what I'm looking for.

Make the assessment and plan easy to read. Referring docs will sometimes glance at the notes. Some of these EMR-generated notes are monstrosities, I’ll get outside pain records and each note says the exact same thing and I have no idea what was actually done or planned that day.

I started getting referrals from a PCP I’ve never talked to, he’s gotten automatic notes from me because my EMR lets me send an efax once we know who your PCP is. My new patient told me I was highly recommended by their PCP. I’m in a pain-saturated area so the only thing I can think of that sets me apart is that you can follow my notes.

The A/P is always:

One line summary about their issue and what I think is going on plus any important nuggets (pending cancer work up, about to have knee replacement, etc)

Then the following template

1. Medications:
2. Studies:
3. Procedures:
4. Rehabilitation:
5. Psychology:
6. Referrals:
7. Follow up:

It makes it a lot easier for me to track what I’m doing with a patient, or to refresh myself for someone I haven’t seen in 3 years. And my staff can follow it too and answer phone calls based on the info. Now it’s helpful for complexity billing as well.

I like that template. Thanks!

 

[Ligament]

The idea would be to make it easier for someone reading the note to find the A&P easily. That way they wouldn't be wasting their time wading through BS. And only the header of "A&P" would be in red, for example.



Point taken.

The idea for references would be to show them my recommendations are evidence based. I'm hoping to do whatever I can to push back against the tide of non-pain boarded 'pain specialists', people running pill mills, people practicing outdated medicine etc.


Right. That is why I said I don't want to write a novella. Something concise is what I'm looking for.

I like that template. Thanks!

Nobody reading your note cares about evidence based anything. They care whether you are taking the patient off their hands.

You sound like a recent fellow who feels as if your attendings are grading you based on your notes. That is now over.

Now you make notes useful for yourself, to protect against medmal, and score insurance billing points in the least painful fashion possible.

 

[deleted131481]

My favorite notes to read are a certain neurosurgeon. About 20 words in a note:


Returns with R L5 pain.
No sensory deficits
5/5 str
MRI without significant narrowing.
PT, pain clinic

 

[bedrock]

My favorite notes to read are a certain neurosurgeon. About 20 words in a note:


Returns with R L5 pain.
No sensory deficits
5/5 str
MRI without significant narrowing.
PT, pain clinic

Lol. I wonder what level he bills for these.

 

[Laryngospasm]

Make notes useful for yourself so you can see the patients history, imaging, last time they had therapy and type if applicable, surgeries, treatments And meds they have tried in the past that have and haven’t worked etc. if the note is useful to you it will be useful to anyone reviewing it. I’ve noticed the heme onc guys do things this way and I think it’s relevant to pain as well.

 

[painfree23]

Lol. I wonder what level he bills for these.

Time

 

[DrMDAware]

Nobody reading your note cares about evidence based anything. They care whether you are taking the patient off their hands.

You sound like a recent fellow who feels as if your attendings are grading you based on your notes. That is now over.

Now you make notes useful for yourself, to protect against medmal, and score insurance billing points in the least painful fashion possible.

Sorry for asking the community for input.

 

[pastafan]

Sorry for asking the community for input.

You have received what should be helpful feedback. I am sorry that you disregard it out of hand. Good luck.

 

[Baron Samedi]

Sorry for asking the community for input.

Consider it like this:

Who are you helping if you spend an extra 10 minutes writing your note or stay late with a stack of charts? There's no medal for World's Most Comprehensive Notewriter. Time is your most valuable asset in life, spend it on things that matter.

 

[DrMDAware]

You have received what should be helpful feedback. I am sorry that you disregard it out of hand. Good luck.

I agree with you. It was helpful. And I'm thankful for it. No need to have been snarky about it, though.

 

[DrMDAware]

Consider it like this:

Who are you helping if you spend an extra 10 minutes writing your note or stay late with a stack of charts? There's no medal for World's Most Comprehensive Notewriter. Time is your most valuable asset in life, spend it on things that matter.

I agree time is valuable. I have a tech background and it wouldn't take me 10 minutes to do this. Think templates, dot phrases, short cuts, macros etc. Like I said in the original post it wouldn't take more time, necessarily.

Who am I helping? That's a good question. Hopefully, I'd be able to bill for it, cover my butt med-legally and also show referring physicians that the treatment is actually based on evidence and I'm a thorough physician. Of course one can do this in other ways.

 

[NJPAIN]

On occasion you will impress a referring physician but not often. My notes are thorough for three reasons:
1. OCD
2. I like to lay out plan A,B and C for myself so I don’t feel like I’m starting from scratch at each visit.
3. You need the details in your note to get treatment approved. I do a little IME, peer review, etc. LOTS of treatment denied for lack of documentation. I used to feel bad about it but now I view poor documentation as sloppiness. Not my job to fill in the blanks for the treating doc.

 

[oreosandsake]

Staple a Benjamin to it when you send it back

 

[Ducttape]

most curt note I have seen - he checked 3 boxes:

[x] Hx unchanged
[x] PE unchanged
[x] Pump refilled.

of course, billed for level 4 fu and pump refill and interrogation.

 

[Crybaby]

The positive feed back I have gotten from a rare surgeon and a few PCP, rheum is mainly info that I put in purely for myself.

I say one positive talking point about patient (to remember the next time I see them) if I don't like them I say nothing. I actually legitimately enjoy hearing about my patient's trips, kids, house remodels and it typically takes only 1-2 minutes. It also sets my clinic aside from pill mill only high volume block shops.

I try to lay out diagnosis and diff dx, plan, back up plan, and convenient locations for PT if pertinent.

Currently working on organization of note, thinking of putting plan before anything else.... I think it looks nice and straight to the point.

 

[painfree23]

most curt note I have seen - he checked 3 boxes:

[x] Hx unchanged
[x] PE unchanged
[x] Pump refilled.

of course, billed for level 4 fu and pump refill and interrogation.

Would u rather him copy forward the previous note and change the date? Pump fills are lvl 4 visits

 

[callmeanesthesia]

The positive feed back I have gotten from a rare surgeon and a few PCP, rheum is mainly info that I put in purely for myself.

I say one positive talking point about patient (to remember the next time I see them) if I don't like them I say nothing. I actually legitimately enjoy hearing about my patient's trips, kids, house remodels and it typically takes only 1-2 minutes. It also sets my clinic aside from pill mill only high volume block shops.

I try to lay out diagnosis and diff dx, plan, back up plan, and convenient locations for PT if pertinent.

Currently working on organization of note, thinking of putting plan before anything else.... I think it looks nice and straight to the point.

I think what would really help is a format that puts a basic old-school SOAP note at the very top, and pushes the EMR and insurance fluff to the bottom. I did something like this in intern year internal medicine. There was so much fluff that would get copied over day to day in the 20 item problem list, so I just put a very brief summary of only the most pertinent overnight changes, new labs, new physical exam, and changes to the plan, as well as a running day by day summary of their hospital course.

 

[Ducttape]

I would rather he write a note - however brief - that talked about the patient and gave a modicum of information in case someone else had to see the patient. what was the doctor considering, what was he planning on doing, and what was the patient's condition.

does not have to be wordy. I have seen 1 sentence A/P notes that accomplish that.

 

[oreosandsake]

Would u rather him copy forward the previous note and change the date? Pump fills are lvl 4 visits

Is there no cpt code for pump fill ?

 

[lobelsteve]

Is there no cpt code for pump fill ?

5 digit code, begins with a 6.
0.67wRVU though.

 

[oreosandsake]

5 digit code, begins with a 6.
0.67wRVU though.

so then... they bill 99214-25 and add on the code?

 

[jonnylingo]

No note needs to read like a novelette. Maddening to have to search for the Impression and Plan. Keep it at the top.

And don't ever forget the "Dear (referring provider). I had the pleasure of seeing this kind patient........Thank you very much for the referral..."

 

[Crybaby]

And don't ever forget the "Dear (referring provider). I had the pleasure of seeing this kind patient........Thank you very much for the referral..."

Haha, that was my pet peeve from residency. Felt way too cheesy....even for me!

 

[Ligament]

Sorry for asking the community for input.

Why? You asked for input and some of us with 10+ years experience have shared it. If I was in your shoes I would have been very pleased, since I was informed nobody cares about my notes except me, lawyers, and insurance companies looking for qualifying data to pay me RVU pellets. Had I known this earlier in my career I would have saved hundreds of hours of my time and many thousands in transcription and scribe fees, probably over $20,000. Use the time and energy for more productive or fun parts of your life.

 

[oreosandsake]

Yes, since you've lost your license It would make sense for me to take over the MED of 990 and Long, short acting benzos, and somas in your ex-con with history of overdose.

Please send more

 

[lobelsteve]

so then... they bill 99214-25 and add on the code?

62368 is reprogram at 0.67
62370 is refill. Only 0.90

 

[oreosandsake]

62368 is reprogram at 0.67
62370 is refill. Only 0.90

the big dollars must be in owning the compounding pharmacy

I dont have the skills to put in a pump.
and I'm not going to manage someone else's.... 🙈

 

[oreosandsake]

62368 is reprogram at 0.67
62370 is refill. Only 0.90

on a side note, they are killing the procedural reimbursements so much that no one will want to do risky things anymore.
seeing a level 4 office visit in 2021 is 1.9 rvu and a level 3 is 1.5 or 1.6?!

 

[Ducttape]

so then... they bill 99214-25 and add on the code?

this guy did. most do.

the big dollars must be in owning the compounding pharmacy

I dont have the skills to put in a pump.
and I'm not going to manage someone else's.... 🙈

you got those skills in fellowship. if you didn't do some pump implants, I'm sure Medtronics or Cosman would be willing to hook you up to shadow someone.

if you really wanted to...


previously, I believe before 2013, one could have a nurse do the pump refill and the doctor would bill for the reprogamming.

 

[Crybaby]

this guy did. most do.


you got those skills in fellowship. if you didn't do some pump implants, I'm sure Medtronics or Cosman would be willing to hook you up to shadow someone.

if you really wanted to...


previously, I believe before 2013, one could have a nurse do the pump refill and the doctor would bill for the reprogamming.

Just curious, is there specific policy on nurse fills currently? I do not manage pumps but I hear about LPNs filling the pumps and often times changing dosing.

 

[yeasports]

I was told by an attending when I was in training: "When it comes to your note longer is not better; better is better."
I think about that often.

 

[Laryngospasm]

Most people who do lots of pumps use nurses to fill. Otherwise you would spend all day filling pumps and make zero money.

 

[Ducttape]

Just curious, is there specific policy on nurse fills currently? I do not manage pumps but I hear about LPNs filling the pumps and often times changing dosing.

short answer - No.

 

[lobelsteve]

Caveat: I have worked a few medmal cases where nurses were filling pumps. Or at least tried to. Also, PA/NP managing pump. More than one death. More than one pocket fill.
I would recommend never allowing anyone you supervise to manage your pump patients. But we thank you for your insurance companys’ deep pockets.