patients to have access to physicians notes

[FutureInternist]

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I'll have to stop writing "older than stated age"

Is “Bitchier than the situation warrants” still allowed 🙂

 

[DrMetal]

You know its sad, because decisions like these are usually made without consulting physicians (or only consulting executive ones who don't practice any more).

And we're such good lap dogs, we'll bow down to anything.

If hospital admin made it a requirement that all physicians have to have a BMI<30 (to exemplify good health), we'd all start our keto diets, no questions asked. [I'd be screwed, b/c I've definitely gained my COVID -20 lbs. I could just blame my "thryoid problem".]

 

[zeloc]

Much of this advice is terrible.

First and foremost, understand the primary goal of documentation is reimbursement.

No, the primary goal of documentation is patient care and patient safety; reimbursement is secondary and never takes priority over patient care.

What you've written should give specific, unambiguous instructions to those carrying out orders and make sense if medicolegal teams get involved. Simultaneously notifying teams of all the thoughts in your head is nice, but should not detract from the primary goal. If you feel like something can not be clearly conveyed through documentation or is a gray area, pick up the phone and call them.

If something is not clearly conveyed through documentation and you are making phone calls to convey this information, it is up to your word during a malpractice case, you are not going to have a clear recollection of what was discussed months/years later in that particular instance, and the lawyers are just going to see the unclear documentation.

For primary teams, try to limit discussion about differentials to only the highest likely conditions and to not recreate an essay from your clinical reasoning course.

Yes, by definition less likely conditions will occur less often, but considering the high import of missed diagnoses, especially that they are a frequent cause of malpractice cases, your omitting a consideration that you had in your note is going to put you in big trouble when a malpractice case occurs and your colleagues did not follow up on something that was in your DDx when they should have and it was no fault of yours.

Secondly, yes you should copy forward for your own sanity but get into the habit of going line-through-line to ensure everything (dates, daily plan, data), etc. is up to date and the plan is reflective of today. Attendings will lose trust in you if they actually read your notes before signing them and see "surgery tomorrow" when the surgery was a week ago (not using dates instead of "tomorrow" is a rookie mistake). These appear to be pointless details in the grand scheme, but we've become so complacent that many of our notes are now meaningless. Not saying we need to overhaul the system, but we need to spend the extra second on the details at times.

Absolutely correct, and this goes for attendings as well.

Last, and most important, any difference of opinion you have with another team should be handled by, as my attending likes to say "picking up the damn phone". Never make disagreements or frustrations with other teams evident in notes. Interns oftentimes document "paged surgery team XYZ, no response" for CYA purposes or take a page out of an RNs playbook and document "RN paged second time, no response".

Yes, the medical record should not be used to express frustration or other negative emotions, but it is critically important to document when you have paged/contacted another team, what methods you used to do so, and what the outcome was. Plenty of physicians have lost massive lawsuits when it came down to another team like surgery not responding when there was an emergency and the primary team did not document the efforts they made to contact the consultant, and conversely it has saved physicians from liability when they have demonstrated that they made appropriate efforts to contact the consultant. Of course in a serious situation you should always escalate things as soon as possible by contacting the attending eg (if you have been dealing with a resident), contacting your administrator on call, making efforts to transfer the pt to another hospital if indicated and if the clinical stability will allow it, etc.

 

[zeloc]

Some of the points made above are wrong - regarding opening one's own practice - this law applies to all electronic records, I do not believe that any practices are exempt.
"Patients have always had access to this" - outpatient notes, yes, but it was never possible at most institutions for patients to get access to inpatient nursing notes, eg, nor inpatient primary team and consultant notes.

In the inpatient setting, where you have highly complex, sick patients, this is going to increase defensive medicine and healthcare costs, with more imaging and more consults. Physicians are going to take more time to document if the some of the documentation changes described above are implemented and the medical record is going to become less useful and less concise. There is a reason for medical jargon - so that doctors can be precise and communicate a maximum of information in a minimum of time. The nationwide effect of this when all the time of each physician is added up and the other downstream effects, when there is already a shortage of doctors, is going to be massive.

The only reason this kind of legislation gets passed is because quality of care is low (relatively) and the cost is high (relatively). Instead of taking measures like this, they should be working on what are the obvious underlying reasons for the dysfunction in US health care. And if it was going to improve outcomes or make patients happier, institutions would already be making inpatient notes available to patients, it would not require legislation to force it. But because of the government-caused shortage of health care workers, healthcare regulations, billing and documentation requirements, and mis-aligned incentives, it does not make financial sense to make patients happier because they don't have much of a choice to shop around because of the shortages, nor to improve care when there is any increased cost, because it will increase the chance of the hospital shuttering since reimbursement is not affected.

 

[chessknt]

No, the primary goal of documentation is patient care and patient safety; reimbursement is secondary and never takes priority over patient care.

Can't say this is remotely true outside of academia that I have seen. Vast majority of notes I read are lists of problems to increase DRG/billing complexity that don't add anything by producing massive lists of problems that have minimal clinical relevance and dilute my ability to discern what is being done or why. This is also true when there is a 14 point ROS every day taking up a page of the note that adds absolutely nothing to care. A list of the imaging reports (including those from weeks ago) also completely useless but 'reviewing' them increases billing complexity.

 

[FutureInternist]

Can't say this is remotely true outside of academia that I have seen. Vast majority of notes I read are lists of problems to increase DRG/billing complexity that don't add anything by producing massive lists of problems that have minimal clinical relevance and dilute my ability to discern what is being done or why. This is also true when there is a 14 point ROS every day taking up a page of the note that adds absolutely nothing to care. A list of the imaging reports (including those from weeks ago) also completely useless but 'reviewing' them increases billing complexity.

Agree that note bloat is done to justify a higher charge.

I think that the ROS is only needed for initial H&P/consult, and not for daily progress notes.

I copy/paste just the impression part of relevant studies and while I have to do the problem list in Epic, I do then group similar issues together in dictated A/P so Severe sepsis, AKI and lactic acidosis all go together.

 

[chessknt]

Agree that note bloat is done to justify a higher charge.

I think that the ROS is only needed for initial H&P/consult, and not for daily progress notes.

I copy/paste just the impression part of relevant studies and while I have to do the problem list in Epic, I do then group similar issues together in dictated A/P so Severe sepsis, AKI and lactic acidosis all go together.

The notes I read routinely at least each electrolyte abnormality as a separate problem with no assessment or plan and half the time they aren't even relevant because they occurred a week ago.

 

[FutureInternist]

Some of the points made above are wrong - regarding opening one's own practice - this law applies to all electronic records, I do not believe that any practices are exempt.
"Patients have always had access to this" - outpatient notes, yes, but it was never possible at most institutions for patients to get access to inpatient nursing notes, eg, nor inpatient primary team and consultant notes.

In the inpatient setting, where you have highly complex, sick patients, this is going to increase defensive medicine and healthcare costs, with more imaging and more consults. Physicians are going to take more time to document if the some of the documentation changes described above are implemented and the medical record is going to become less useful and less concise. There is a reason for medical jargon - so that doctors can be precise and communicate a maximum of information in a minimum of time. The nationwide effect of this when all the time of each physician is added up and the other downstream effects, when there is already a shortage of doctors, is going to be massive.

The only reason this kind of legislation gets passed is because quality of care is low (relatively) and the cost is high (relatively). Instead of taking measures like this, they should be working on what are the obvious underlying reasons for the dysfunction in US health care. And if it was going to improve outcomes or make patients happier, institutions would already be making inpatient notes available to patients, it would not require legislation to force it. But because of the government-caused shortage of health care workers, healthcare regulations, billing and documentation requirements, and mis-aligned incentives, it does not make financial sense to make patients happier because they don't have much of a choice to shop around because of the shortages, nor to improve care when there is any increased cost, because it will increase the chance of the hospital shuttering since reimbursement is not affected.

My job has had it for > 2 years and we haven’t seen much change in docs progress notes.

It IS the pt’s info, so now they just get access to it in real-time rather than after the fact.

I haven’t had any issues with it since we started it since most pts don’t actually access them and those that do were the types that would have found something to complain about anyway.

 

[FutureInternist]

The notes I read routinely at least each electrolyte abnormality as a separate problem with no assessment or plan and half the time they aren't even relevant because they occurred a week ago.

That’s just idiotic.

I train all the new docs in Epic so perhaps I have a higher “burden” to have cleaner notes.... but I only got that job since I did my notes the “correct” way from the get-go.

 

[chessknt]

That’s just idiotic.

I train all the new docs in Epic so perhaps I have a higher “burden” to have cleaner notes.... but I only got that job since I did my notes the “correct” way from the get-go.

I assume at some point some note auditor explain to them that the more problems they had the more justifiable and defensible their higher billing would be. Fortunately I bill critical care most of the timewhich essentially has no documentation standards in terms of number of problems so I don't have to deal with this BS most of the time and write my notes how I see fit but the e&m coding system is beyond dumband I feel for my hospitalist colleagues who have to abide by its rules at all times

 

[DrMetal]

This is how I'm going to chart from now on: PGY-1 Writes Admission Note That Does Not Contain a Single English Word | GomerBlog

HPI:
54M w/ MMP incl. COPD, HFrEF, stg. IV SSC (?1°, w/ mets to LLL c/b CAP x 3, mets to L-S c/b LBP), p/w CP x 2hr i/s/o SOB & F/C x 3 d. Tmax 102. ROS neg 4 N/V/D, DVT/PE. ...

 

[chessknt]

This is how I'm going to chart from now on: PGY-1 Writes Admission Note That Does Not Contain a Single English Word | GomerBlog

HPI:
54M w/ MMP incl. COPD, HFrEF, stg. IV SSC (?1°, w/ mets to LLL c/b CAP x 3, mets to L-S c/b LBP), p/w CP x 2hr i/s/o SOB & F/C x 3 d. Tmax 102. ROS neg 4 N/V/D, DVT/PE. ...

Optho has mastered this. Noone outside their own specialty can understand their notes.

 

[rokshana]

Agree that note bloat is done to justify a higher charge.

I think that the ROS is only needed for initial H&P/consult, and not for daily progress notes.

I copy/paste just the impression part of relevant studies and while I have to do the problem list in Epic, I do then group similar issues together in dictated A/P so Severe sepsis, AKI and lactic acidosis all go together.

actually the ROS is required for f/u notes, but less elements are need in subsequent notes

 

[FutureInternist]

actually the ROS is required for f/u notes, but less elements are need in subsequent notes

That’s weird.
Our EMR does not import an ROS for progress notes and I don’t put anything except “No acute events o/n” in Subjective.

No issues in 7 years 🤔

 

[Redpancreas]

Much of this advice is terrible.

I did not anticipate a negative response to my advice, but I can see your points and therefore want to clarify my post.

1.) Patient Safety: I do not think documentation is an effective safety measure. It is often the contributor to medical errors (reading outdated/careless documentation) and as a result many have learnt to not even read it (my perspective as a resident). I think in-person communication is the most effective and timely. That said, your documentation should be flawless.

2.) The big-picture I tried to convey was that a note should read more like cookbook instructions (consultant) or an anticipated timeline of events (primary progress note) as opposed to a mini-thesis. After 20 years of school, I had a tendency to lean towards the latter. Resultantly, I was taught that there are standards of care that are understood and do not need re-stating. I do see your point about a lawsuit coming back 20 years down the road and your documentation not including details that defend your rationale. I try to phrase things specifically, but succinctly. When done, I go line-by-line as an editor to find 3 kinds of errors: 1) Discrepancy between documented and written plan 2) Meets the standard of care and if not, what is my justification 3) Accuracy.

3) Regarding documenting "XYZ team did not show up", I think a better place to write that is a confidential reporting system your hospital uses as that should be available during litigation as well. Encouraging other healthcare team members to report it (after the issue's been addressed) adds a level of verification.

 

[Kakoy]

I already have an incident!
I spent an hr with a pt in her 30 min appt answering questions ( like she wants to know mechanism, nitty gritty details of pathophysi, I went into proteins and receptors) and write in my note that I spent significantly answering patient’s questions!
She wrote me a message the next morning that by writing she had a lot questions sound judgemental!
I am over this and it’s only been 3 wks!

 

[zeloc]

Can't say this is remotely true outside of academia that I have seen. Vast majority of notes I read are lists of problems to increase DRG/billing complexity that don't add anything by producing massive lists of problems that have minimal clinical relevance and dilute my ability to discern what is being done or why. This is also true when there is a 14 point ROS every day taking up a page of the note that adds absolutely nothing to care. A list of the imaging reports (including those from weeks ago) also completely useless but 'reviewing' them increases billing complexity.

So because the "vast majority of notes you read" "have minimal clinical relevance and dilute your ability to discern what is being done and why", that means that everyone else should aim to write useless notes?

My job has had it for > 2 years and we haven’t seen much change in docs progress notes.

It IS the pt’s info, so now they just get access to it in real-time rather than after the fact.

I haven’t had any issues with it since we started it since most pts don’t actually access them and those that do were the types that would have found something to complain about anyway.

Please clarify whether you are referring to inpatient or outpatient. I highly doubt that pts previously had access to inpatient nursing notes after the fact, which is what I mentioned in my post.

I did not anticipate a negative response to my advice, but I can see your points and therefore want to clarify my post.

1.) Patient Safety: I do not think documentation is an effective safety measure. It is often the contributor to medical errors (reading outdated/careless documentation) and as a result many have learnt to not even read it (my perspective as a resident). I think in-person communication is the most effective and timely. That said, your documentation should be flawless.

Because documentation is not an effective safety measure where you are currently practicing does not mean that physicians should not aim for it to be an effective safety measure.

2.) The big-picture I tried to convey was that a note should read more like cookbook instructions (consultant) or an anticipated timeline of events (primary progress note) as opposed to a mini-thesis. After 20 years of school, I had a tendency to lean towards the latter. Resultantly, I was taught that there are standards of care that are understood and do not need re-stating. I do see your point about a lawsuit coming back 20 years down the road and your documentation not including details that defend your rationale. I try to phrase things specifically, but succinctly. When done, I go line-by-line as an editor to find 3 kinds of errors: 1) Discrepancy between documented and written plan 2) Meets the standard of care and if not, what is my justification 3) Accuracy.

A lawsuit will not come 20 years down the road and physicians greatly overestimate their ability to remember details of historical clinical encounters. If I chose a pt at random you saw 2 months ago, your memory of it will be hazy, even if you have access to the notes you wrote, and certainly there will be a lot of detail lacking compared to if I asked you about the pt the following day after the encounter.

3) Regarding documenting "XYZ team did not show up", I think a better place to write that is a confidential reporting system your hospital uses as that should be available during litigation as well. Encouraging other healthcare team members to report it (after the issue's been addressed) adds a level of verification.

I'm not aware of such a system at my hospital. Also such a system needs to document the date and time of each note, because otherwise the notes could be falsified.
I am not referring to hypotheticals - look at a number of malpractice cases, what was and was not documented in terms of reaching out to a consultant, and what the outcome was. If you are not documenting it in the clinical record, even the next day you are going to be facing questions from other clinical colleagues as to why you didn't contact surgery and the medical record is conspicuously blank.

 

[chessknt]

The fact remains that the note, as it exists in modern times, is there to fulfill the preposterous and onerous E/M billing requirements. If its purpose was to clearly communicate clinical information CMS would institute sort of punitive measure for 90% of the bull**** clogging up a note that has no impact on patient care. You dont get sued for unclear documentation but you can lose a suit because of it. I have no doubt that if we werent worried about documenting 99 problems/studies 'reviewed'/12 point exam that didnt change a damn thing in our notes to maximize DRG/EM billing there would be a lot less missed in documentation. I do some e-icu type work and since there is no CMS billing requirement I get to document exactly what I want--my notes average a few sentences but when a lot is going on I very clearly lay out what I was thinking and why because I know that the person picking the patient is a) not an intensivist and b)not going to be able to talk to me and my note is the only form of communication I will have with that provider. I dont have to worry about documenting a thyroid exam or complex history or any other BS, it is truly amazing.

Its cool that at your hospital many are documenting everything exhaustively and clearly with amazing clinical utility in their notes--I can tell you at the 6+ hospitals I have worked in the past 4 years (plus the 14+ I see via eICU work) I have never seen that outside of trainee-written academic notes (trainees in community centers write garbage notes too from what I saw).

 

[FutureInternist]

@zeloc

Your post said inpt nursing notes nor inpt primary notes or consultant notes.

I do not know about nursing notes but for sure my job has given pt’s ability to access IM (primary team), as well as all consultant notes, labs, images etc in real time for at least 2 (going on 3) years.

I have been at this job for 7 years... and haven’t noticed any changes (even though nursing makes a big deal of informing each pt upon admit of this feature, maybe not many pts actually look it up?)

 

[zeloc]

The fact remains that the note, as it exists in modern times, is there to fulfill the preposterous and onerous E/M billing requirements. If its purpose was to clearly communicate clinical information CMS would institute sort of punitive measure for 90% of the bull**** clogging up a note that has no impact on patient care.

CMS has no idea what they're doing, so their lack of doing something does not indicate that extant notes are exemplary (as you have pointed out), and contrariwise, because they require something does not mean that's the way it should be (like preposterous and onerous billing requirements).

The 30-fold increase in administrators over doctors/nurses over the past 50 years does not mean that it was necessary or that thats how medicine should be, and I am not going to recommend to anyone to further increase administrators by another 30-fold over the increase in doctors/nurses, just like I am not going to advise clinicians to think of the medical record as being primarily for billing, which is what was advocated by the trainee above as advice for how clinicians should think about documentation, when clinicians should think of it as being primarily for clinical care, and secondarily for billing.

 

[zeloc]

@zeloc

Your post said inpt nursing notes nor inpt primary notes or consultant notes.

I do not know about nursing notes but for sure my job has given pt’s ability to access IM (primary team), as well as all consultant notes, labs, images etc in real time for at least 2 (going on 3) years.

I have been at this job for 7 years... and haven’t noticed any changes (even though nursing makes a big deal of informing each pt upon admit of this feature, maybe not many pts actually look it up?)

Am curious if they made outpatient and inpatient notes available at the same time at your institution? Most places allowed access to outpt notes several years (at least) before inpatient notes were made available, and AFAIK there were very few institutions that allowed access to inpatient notes until last month.

 

[FutureInternist]

Am curious if they made outpatient and inpatient notes available at the same time at your institution? Most places allowed access to outpt notes several years (at least) before inpatient notes were made available, and AFAIK there were very few institutions that allowed access to inpatient notes until last month.

Not sure... I just do inpt hospitalist work.
Maybe there were plans to make outpt available and management thought, Why not just make all of them available?

I will say that a lot of the “doomsday” scenarios that my colleagues were worried about, never happened.

Just like with Dragon, we (those on the different committees), just made an executive decision to shut down telephone transcription and release the Dragon app. (despite opposition)
A week later and most docs were like “Why didn’t we do this sooner” 😡

 

[zeloc]

This law applies to all outpatient practices using electronic records as well, right?

 

[gutonc]

This law applies to all outpatient practices using electronic records as well, right?

Yes.

 

[tantacles]

That’s weird.
Our EMR does not import an ROS for progress notes and I don’t put anything except “No acute events o/n” in Subjective.

No issues in 7 years 🤔

Only need 2/3 billable elements in progress notes, so if your exam and MDM are always complete, that’s probably why.