Residents writing fake notes?

[quickfeet]

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On my sub-i right now. The residents on our service all write notes on their patients, but apparently, the attending also writes his/her own note (they have scribes). The residents complain about writing notes, and that the attendings never read them.

Seems like busy work to me? I.e. alogn the lines of what I did as an M3 (wrote fake notes in Epic that would jsut get deleted 5 days after patient was discharged).

Is this common at residency programs?

 

[SurfingDoctor]

I can tell you this is true where I practice, though I admit I'm unclear why. The residents don't write notes and generally speaking, have less understanding of the patients or their physiology. Unfortunately, at least from my own peripheral understanding, they requested this change. Little to they know, by doing so, they disincentivise their own learning. If a bedside nurse can tell on rounds that a trainee does understand what is going on with a patient, they are unlikely to ask them for guidance when something goes amiss, thus leaving them out of the loop. If nothing else, notes help organize thoughts succinctly.

 

[Gastrapathy]

Follow the money. Can't bill for "agree with above". Maybe the residents need to each be given a cookie.

 

[PikminOC]

As med students we used to write notes

 

[quickfeet]

Follow the money. Can't bill for "agree with above". Maybe the residents need to each be given a cookie.

Yes sir, but from what I understand, you can still bill for a residents note so long as the attending's addendum includes certain things. AFAIK the attending herself does not need to write a whole separate note repeating everything the resident already gathered?

 

[mimelim]

Follow the money. Can't bill for "agree with above". Maybe the residents need to each be given a cookie.

Yes you can. You have to actually attest the note, but you certainly can bill based on the content of the note. We do this all the time and to be sure, I ran it by our medicare/billing specialist today.

 

[Gastrapathy]

I oversimplified a bit and while it is possible to get credit via attestion of a resident note, its also an easy way to lose money:
https://www.cms.gov/Outreach-and-Ed.../Teaching-Physicians-Fact-Sheet-ICN006437.pdf

http://www.todayshospitalist.com/index.php?b=articles_read&cnt=19

For individuals billing medicare and, most importantly, private insurers who each have their own sets of rules, you avoid the hassle by writing your own note. I know of at least one insurer that reflexively denied anything that was written and cosigned (even with a nice "medicare approved" attestation). You could go back and argue to get paid but I'm sure we lost money. You won't ever have to deal with a question as to the adequacy of an attestation if you write the note yourself.

A second reason is that your coders probably aren't crediting you with the work so in places where compensation is RVU driven, it can hurt your apparent productivity (again, follow the money)

Trust me, this is why they are doing it. It is something you will often see in semi-academic places where the doctors aren't salaried and are more aware of losing a small part of their collections.

 

[Stagg737]

Residents don't write notes? Wtf kind of program is this? I'm an M3 and I write notes on some of my rotations (obviously reviewed and signed by a physician). Is this a common thing in residency?

 

[Gastrapathy]

They write them. The attendings just write their own too. Its frustrating because the residents don't even read resident notes when there is an attending note too.

 

[SurfingDoctor]

They write them. The attendings just write their own too.

Like I said, where I work, the residents don't write daily notes. I suspect that it is not unique to my program, but I also bet it is more of the exception than the rule. I certainly have my opinion on this subject matter within my own institute, but then again, my opinion is irrelevant.

 

[cbrons]

I oversimplified a bit and while it is possible to get credit via attestion of a resident note, its also an easy way to lose money:
https://www.cms.gov/Outreach-and-Ed.../Teaching-Physicians-Fact-Sheet-ICN006437.pdf

http://www.todayshospitalist.com/index.php?b=articles_read&cnt=19

For individuals billing medicare and, most importantly, private insurers who each have their own sets of rules, you avoid the hassle by writing your own note. I know of at least one insurer that reflexively denied anything that was written and cosigned (even with a nice "medicare approved" attestation). You could go back and argue to get paid but I'm sure we lost money. You won't ever have to deal with a question as to the adequacy of an attestation if you write the note yourself.

A second reason is that your coders probably aren't crediting you with the work so in places where compensation is RVU driven, it can hurt your apparent productivity (again, follow the money)

Trust me, this is why they are doing it. It is something you will often see in semi-academic places where the doctors aren't salaried and are more aware of losing a small part of their collections.

If the attendings are writing an entirely separate note, what is the purpose of residents even writing 1? Seems like pure busy work.

Is this the same thing with mid-level notes?

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[Psai]

If the attendings are writing an entirely separate note, what is the purpose of residents even writing 1? Seems like pure busy work.

Is this the same thing with mid-level notes?

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Well attending notes usually just have the pertinent info. All the crap needed for billing like full review of systems, social history, family history, full exam, etc. are in the resident note. I think it's good practice to write a note and compare it to a note written by someone ahead of you in education but depends on how many you have to write and how much you're actually learning. There are diminishing returns.

Writing notes do help with organizing your thoughts and following along with the patient's course in my opinion.

 

[takeurmeds02]

Short-term, it does seem like a waste of time, but long-term residents are going to have to write their own notes in the future anyway. Might as well get the practice. I can't imagine a resident getting out into real practice not knowing how to write a note. Talk about a productivity sink in addition to any other legal or billing issues.

On a somewhat similar note, I would scribe for one doc in particular who would completely trash my notes and make me feel utterly useless while the majority of the other docs would simply skim my notes, make small changes, and hit sign.

At the end of the day, the attending is ultimately responsible so some want to be sure that everything is done strictly to their liking even down to the wording. Sucks but what are you going to do?

 

[mimelim]

I oversimplified a bit and while it is possible to get credit via attestion of a resident note, its also an easy way to lose money:
https://www.cms.gov/Outreach-and-Ed.../Teaching-Physicians-Fact-Sheet-ICN006437.pdf

http://www.todayshospitalist.com/index.php?b=articles_read&cnt=19

For individuals billing medicare and, most importantly, private insurers who each have their own sets of rules, you avoid the hassle by writing your own note. I know of at least one insurer that reflexively denied anything that was written and cosigned (even with a nice "medicare approved" attestation). You could go back and argue to get paid but I'm sure we lost money. You won't ever have to deal with a question as to the adequacy of an attestation if you write the note yourself.

A second reason is that your coders probably aren't crediting you with the work so in places where compensation is RVU driven, it can hurt your apparent productivity (again, follow the money)

Trust me, this is why they are doing it. It is something you will often see in semi-academic places where the doctors aren't salaried and are more aware of losing a small part of their collections.

Our surgeons are compensated by RVU based models and for all practical purposes function as private practice physicians as far as compensation goes. When I write notes, I write ICD 10 codes for my note. For my operative reports I put CPT codes.

Yes, if you document poorly, then yes, your compensation will be hurt. Yes, that means that unless you trust your residents, you have to actually review what they wrote and what they are billing. It is expected that our residents will document their notes with the appropriate level of detail in HPI/ROS/PE etc to bill at the correct level. If they don't, they get an e-mail/delinquency from the billers/coders. It is as much a part of the education in a training program as learning to operate.

 

[<L>]

Our surgeons are compensated by RVU based models and for all practical purposes function as private practice physicians as far as compensation goes. When I write notes, I write ICD 10 codes for my note. For my operative reports I put CPT codes.

Yes, if you document poorly, then yes, your compensation will be hurt. Yes, that means that unless you trust your residents, you have to actually review what they wrote and what they are billing. It is expected that our residents will document their notes with the appropriate level of detail in HPI/ROS/PE etc to bill at the correct level. If they don't, they get an e-mail/delinquency from the billers/coders. It is as much a part of the education in a training program as learning to operate.

I'm always a little awed at the number of MDs who leave residency with no concept of how to code in their respective specialty.

 

[chipwhitley]

I'm always a little awed at the number of MDs who leave residency with no concept of how to code in their respective specialty.

I didn't realize the purpose of residency was to teach you how to improve your billing.

 

[<L>]

I didn't realize the purpose of residency was to teach you how to improve your billing.

The purpose of residency is to teach you do do your ****ing job.

 

[chipwhitley]

The purpose of residency is to teach you do do your ****ing job.

That's funny, because in my residency they seem to be using me to do everyone's ****ing job, including the nurses, social workers, clerks and patient transport. Sounds more like the purpose of residency is to exploit my cheap labor.

 

[VisionaryTics]

That's funny, because in my residency they seem to be using me to do everyone's ****ing job, including the nurses, social workers, clerks and patient transport. Sounds more like the purpose of residency is to exploit my cheap labor.

Yes, but when you graduate, you go from being cheap labor, to being a not-so-cheap commodity. And your degree of not-so-cheap depends on your ability to bill and code properly.

 

[chipwhitley]

Yes, but when you graduate, you go from being cheap labor, to being a not-so-cheap commodity. And your degree of not-so-cheap depends on your ability to bill and code properly.

Isn't it sad that my value is based on my ability to select the proper codes for a bill and not the actual quality of my work?

 

[Ismet]

They write them. The attendings just write their own too. Its frustrating because the residents don't even read resident notes when there is an attending note too.

The attendings here don't write their own notes if there are residents on the service. They addend the resident note.

I can tell you this is true where I practice, though I admit I'm unclear why. The residents don't write notes and generally speaking, have less understanding of the patients or their physiology. Unfortunately, at least from my own peripheral understanding, they requested this change. Little to they know, by doing so, they disincentivise their own learning. If a bedside nurse can tell on rounds that a trainee does understand what is going on with a patient, they are unlikely to ask them for guidance when something goes amiss, thus leaving them out of the loop. If nothing else, notes help organize thoughts succinctly.

Writing notes is by far my least favorite part of my job, but I wouldn't request to not write notes for the exact reasons you listed. Granted I've only been here 4 months, but I feel like we have a great balance of autonomy and supervision, we know our patients very well, and we're the ones the nurses call (though understandably in July they tended to call my senior and not me...but that has since changed). As much as I hate writing notes, especially ending a clinic day with a mountain of them, I do see a great deal of utility in doing them.

 

[twospadz]

I'm in a bit of a pickle. I just got in trouble with my fellow as a medical school student for copying their plan and pasting it on my note but tweaking it a bit. As students our notes don't count. How bad do you guys think I slipped up?

 

[SurfingDoctor]

Writing notes is by far my least favorite part of my job, but I wouldn't request to not write notes for the exact reasons you listed. Granted I've only been here 4 months, but I feel like we have a great balance of autonomy and supervision, we know our patients very well, and we're the ones the nurses call (though understandably in July they tended to call my senior and not me...but that has since changed). As much as I hate writing notes, especially ending a clinic day with a mountain of them, I do see a great deal of utility in doing them.

It is not a fun part of the job, but it is a necessary part of the job. Additionally, I can't tell you the number of times I've thought of something new or looked at a problem differently while writing my notes. I don't know why the residents requested to write no notes (or why anyone went along with that), but I can tell you, they essentially made themselves superfluous. Ironically, then they complain that they get ignored. Can't please them all.

 

[Ismet]

I'm in a bit of a pickle. I just got in trouble with my fellow as a medical school student for copying their plan and pasting it on my note but tweaking it a bit. As students our notes don't count. How bad do you guys think I slipped up?

Almost as bad as sitting down during rounds.

Jk. Just don't do it again. Your notes don't count for billing purposes, but they count for your learning. If you just copy the fellow's plan, what's the point of even writing the note? Did you yourself try to think up a differential and then think up a plan to go with that differential? Or just take the easy way out and plagiarize the thinking that someone else did?

It's fine (and expected) to reference the notes of people ahead of you. That's how you learn how it's done. I would always check my plan with the resident or fellow note in med school, AFTER I made due diligence at trying it myself. Because there will come a time when you have to produce it yourself and can't copy off of anyone, so you should start practicing that now.

 

[MiaMia14]

We literally write almost every note in our program. The attending will do the "agree with above" deal. And not even on every note. They will do maybe one in the morning and on labor and delivery we write notes every 2 hours...If an attending writes a note we generally only read it to see if they wrote a different plan or added something. The resident notes are much more comprehensive as we have been the ones managing the patient for the most part. The tired resident in me is jealous of the places that are more lax about the notes, but the I wanna be the best Dr. I can be resident in me is like wtf documenting and doing it well is like half of our job...


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[twospadz]

Almost as bad as sitting down during rounds.

Jk. Just don't do it again. Your notes don't count for billing purposes, but they count for your learning. If you just copy the fellow's plan, what's the point of even writing the note? Did you yourself try to think up a differential and then think up a plan to go with that differential? Or just take the easy way out and plagiarize the thinking that someone else did?

It's fine (and expected) to reference the notes of people ahead of you. That's how you learn how it's done. I would always check my plan with the resident or fellow note in med school, AFTER I made due diligence at trying it myself. Because there will come a time when you have to produce it yourself and can't copy off of anyone, so you should start practicing that now.

Thanks man. This was a great response. Will avoid doing this again at all costs. I also appreciate you didn't come off jerkish or condescending. For me, this was a low point.

 

[cbrons]

I think it's good practice to write a note and compare it to a note written by someone ahead of you

the attending notes here are absolutely worthless. Only exception are the ones written by the scribes, which they write based upon the oral presentation of the intern or sub-i while the attending is standing right next to them.

HPI: Obese black F 34 yo hx alcohol admitted w/ pancreatitis.

Exam:
100% template with everything even seriously unlikely exam elements such as funduscopic and otoscopic findings

A:
AP

P:
See orders

🤣

 

[cbrons]

I'm in a bit of a pickle. I just got in trouble with my fellow as a medical school student for copying their plan and pasting it on my note but tweaking it a bit. As students our notes don't count. How bad do you guys think I slipped up?

Extremely surprised he even read ur note.
lol

 

[augeremt]

I'm in a bit of a pickle. I just got in trouble with my fellow as a medical school student for copying their plan and pasting it on my note but tweaking it a bit. As students our notes don't count. How bad do you guys think I slipped up?

Same thing happened to me except I put my foot in my mouth by telling the resident, "It'd be great if you taught us how to write notes. I've been getting by with copying and pasting until now." Not quite what I meant (I'd been using previous notes as a template, not direct copy/paste) but my resident then went back and read through the notes of the entire team and caught a few copy/pasted plans that she understandably was not pleased with. She did teach us how to write notes after that, though.

I ended the rotation with evals from the same resident saying "excellent note-writing", among other positive things.

You can definitely recover. Just don't do it again.

 

[Raryn]

I've never seen an attending write a full note when a resident/fellow saw the patients and wrote a note. Is this specialty specific?

As far as I know, universally, unlike medical students (from whom only family hx/social hx/ROS can be counted), the entire note documented by a resident counts for billing. If that note has all the appropriate components, the attending only needs to write an appropriate attestation that they confirmed the critical portions of the history/physical findings and agree with the plan (with changes if necessary). They can bill at whatever level they would if they wrote the same note. The only exeption is in primary care if the attending doesn't physically see the patient, but that's irrelevant here.

That said, it is entirely possible that the resident note doesn't include enough components to bill at the desired level. The top level consult note for example requires you to document examination of 9 body systems (which is dumb as hell when only 1-2 systems are relevant, but thems the rules) including vitals. So if the resident/fellow only documents 7 systems+vitals, that level can't be billed without the attending adding another one.

The solution there is not to invalidate the work of the trainee by doing your own note, but to fix it in your addendum and then teach the trainee with a reasonable explanation of why it's important. They may resent having to do extra work to "improve" their documentation (by making it less focused) for you to get paid, but that's appropriate education (that I certainly didn't get in residency, but am working on now in fellowship).

I know of no requirements from any insurer, medicare or otherwise, that the attending write their own note. The behavior described above with an insurer blocking all attested to notes unless appealed sounds like something that should be reported to the state insurance controller.

 

[ProfMD]

Notes serve three purposes:
1) Explain your assessment and plan so that other caregivers know what you are doing/thinking.
2) Protect you in the case of a lawsuit.
3) Billing.

Attendings can bill based on resident notes, but the addendum has to be substantial enough to make it clear to the payers that the attending saw the patient and did some work. So, "seen and agree" is generally not acceptable. However, something along the lines of "I have seen and examined the patient and agree with Dr. -----'s findings, assessment, and plan" is acceptable. I do the latter but then add a little blurb with pertinent exam findings and a statement that I personally reviewed imaging studies in order to protect myself.

Unfortunately, with he rise of electronic boiler plate notes, purposes 1 and 2 have fallen by the wayside and purpose 3 is the only thing that is being accomplished. When I see new consults in clinic, nine times out of ten, I have no idea what is going on from reading the Epic generated garbage note (that is, if we get notes at all).

As a resident, you need to learn to write notes that serve all three purposes.

 

[Mad Jack]

The purpose of residency is to teach you do do your ****ing job.

Billing is part of the job.

 

[<L>]

Billing is part of the job.

exactly.

 

[Mad Jack]

exactly.

It's funny how a lot of people miss that though, as if learning tedious but necessary things is somehow a waste of time.

 

[<L>]

It's funny how a lot of people miss that though, as if learning tedious but necessary things is somehow a waste of time.

I want to create an ultrarealistic version of Grays or Chicago Med or The Night Shift. It involves 40 minutes of residents sitting around in a windowless room typing and bitching to each other and 10 minutes of the other stuff you see on the shows.

 

[chipwhitley]

Billing is part of the job.

It is, and trust me, I make sure I learn everything I need to know about it and I'm ready to put it all into practice when I'm done here and it's affecting my salary. However, right now I couldn't care less about increasing my billing because I don't see a single cent out of any additional money I can make for them. So unless they get on my case about it (which they do sometimes), I do the bare minimum in my notes.

 

[VisionaryTics]

It is, and trust me, I make sure I learn everything I need to know about it and I'm ready to put it all into practice when I'm done here and it's affecting my salary. However, right now I couldn't care less about increasing my billing because I don't see a single cent out of any additional money I can make for them. So unless they get on my case about it (which they do sometimes), I do the bare minimum in my notes.

You know, this is like...your job.

 

[<L>]

Unsurprisingly short-sighted of you.

Even if you aren't directly getting money out of the deal, there is a lot of benefit to you as a trainee being part of a financially sound department. The more overhead a department has, the more likely they are to invest it back into the residency program and the department. That's how things like midlevels get hired to offload trainees, or how programs justify spending money on research, travel, book funds, etc. Deliberately bilking your program out of easy revenue doesn't exactly help improve the training environment; it also creates more work for your attendings who are forced to try and upcode all your documentation and they are unlikely to respond positively to it.

Careful SS, you'll trigger some people here.

 

[mimelim]

It is, and trust me, I make sure I learn everything I need to know about it and I'm ready to put it all into practice when I'm done here and it's affecting my salary. However, right now I couldn't care less about increasing my billing because I don't see a single cent out of any additional money I can make for them. So unless they get on my case about it (which they do sometimes), I do the bare minimum in my notes.

The guy bitching about being stuck picking up other people's slack creating more work for others and doing such a ****ty job that he has to be reminded to do it. How surprising.

 

[IRorBustguy]

Follow the money. Can't bill for "agree with above". Maybe the residents need to each be given a cookie.

this is 100% wrong. cant bill medical student notes, but you can certainly bill resident notes PROVIDED that they are addended by attendings

 

[Gastrapathy]

this is 100% wrong. cant bill medical student notes, but you can certainly bill resident notes PROVIDED that they are addended by attendings

sigh. I guess they must just be doing it for fun. Did you read any of the REST of this thread or either of the references I provided?

 

[Raryn]

sigh. I guess they must just be doing it for fun. Did you read any of the REST of this thread or either of the references I provided?

Attendings can still bill off a properly attested to note for every insurance company I'm aware of... in three states.

Your comment "I know of at least one insurer that reflexively denied anything that was written and cosigned" was especially concerning, b/c that's outright fraudulent on the insurance companies part. I knew of one doing something similar that had to pay up big time once it was reported to the state insurance controller.

 

[Light Yagami]

Somewhat related, the outpatient component of my surgery elective is at the attending's private clinic outside the hospital. Often I am told by the nurse to write notes on patients that I have not seen, but the attending saw by himself. Basically, I have to transcribe the attending's handwritten notes of the patient encounter into the EHR. I have my own login to the EHR. Is this even legal? I hate doing it and learn nothing from it; I didn't sign up for this rotation to be a scribe. It takes forever to do because the attending's handwriting is horrible.

 

[DoctwoB]

At my program we write the notes and have been coached on billing issues. We are basically expected to write a level 5 note on all encounters in terms of hpi, histories, exam, ROS, etc, and the attending either co-signs or copy pastes the note and chooses the billing level based on the medical decision making portion.

 

[boogaaloo]

Follow the money. Can't bill for "agree with above". Maybe the residents need to each be given a cookie.

Really?