SOAP notes and rounding just seem so pointless

[sliceofbread136]

It seems like 80% of the day is spent talking about doing things (ie rounding) and writing useless SOAP notes. Wouldn't it be better to give a quick summary of a patient and what needs to be done that day (kind of like a handoff) and instead of a soap note just write a quick paragraph summarizing the days changes? To me it's seems like it would be quicker, more efficient and with much less useless chart clutter

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[Slack3r]

Go into surgery.

 

[zeppelinpage4]

It seems like 80% of the day is spent talking about doing things (ie rounding) and writing useless SOAP notes. Wouldn't it be better to give a quick summary of a patient and what needs to be done that day (kind of like a handoff) and instead of a soap note just write a quick paragraph summarizing the days changes? To me it's seems like it would be quicker, more efficient and with much less useless chart clutter

The first bolded bit, I may be missing something but that sounds like morning sign out.

To the second bolded part, that's pretty much what our surgery soap notes were like. The emphasis was always on being concise, getting through rounds by 7am and hitting the OR the rest of the day until afternoon sign out for the night team. At least that's all I saw, unless the docs were doing tons more paperwork behind the scenes.
I'm not sure if other hospitals are different, but if you haven't had it yet, surgery might be a pleasant surprise.

And yes I completely agree, all the constant rounding and note writing of IM wasn't what I expected going into 3rd year. I'm not a fan either, though I'm most certainly headed FM or peds, so I'll have to get used to lots of paper work and notes I guess.

 

[Cytarabine]

http://gomerblog.com/2014/12/soap-note/

 

[Psai]

Welcome to modern medicine. Thanks to insurance companies, lawyers and the government, taking care of the virtual patient and hitting all the right numbers is much more important than the sick person that needs your help. Perverse incentives arise when the patient doesn't pay you and everyone else is doing their best to rob you

 

[Snoopy2006]

SOAP notes nowadays in the EMR are meant more for billing/insurance companies than they are for the patient's benefit. Don't get me wrong, a good SOAP helps communicate to specialists and consultants, but the patient takes a backseat to "meaningful use, the hospital's revenue, and CYA medicine.

I agree that it borders on absurd. The foreign residents I met were always amazed by how little time they spent at the bedside here. Makes much more sense to write a quick, uncluttered note, and have time to round twice later in the day to see how your morning's plan/changes affected your patient.

 

[HelpPleaseMD]

It seems like 80% of the day is spent talking about doing things (ie rounding) and writing useless SOAP notes. Wouldn't it be better to give a quick summary of a patient and what needs to be done that day (kind of like a handoff) and instead of a soap note just write a quick paragraph summarizing the days changes? To me it's seems like it would be quicker, more efficient and with much less useless chart clutter

that is what academic IM is. if the attendings just told you what to do you'd come out knowing very little.
choose a different field.

 

[sliceofbread136]

that is what academic IM is. if the attendings just told you what to do you'd come out knowing very little.
choose a different field.

you don't understand, you would still come up with a plan just say it in not so many words. And type a much shorter note

 

[Psai]

Note I wish I could write:
Patient doing well, no active bleeding per rectum, sob resolved after transfusion. Afebrile, p 80s, bp 110s/60s, 12 breaths/min, sat 96% on ra, exam benign, hgb stable at 9. Likely upper gi bleed secondary to gastritis from nsaid use, currently stable. Seen by GI, planning egd and colonoscopy in am, NPO since midnight and bowel prepped. Started iv ppi. Will continue to monitor.



Actual note:
HISTORY: Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath. Please see dictated ICU transfer note yesterday detailing the need for emergent transfer transfusion and EGD in this patient. Over the last 24 hours, the patient has received 2 units of packed red blood cells and his hematocrit and hemoglobin have returned to their baseline of approximately 11 appropriate for hemoglobin value. He also underwent EGD earlier today with Dr. X. I have discussed the case with him at length earlier this afternoon and the patient had symptoms of ulcerative esophagitis with no active bleeding. Dr. X recommended to increase the doses of his proton pump inhibitor and to avoid NSAIDs in the future. The patient today complains that he is still having issues with shortness of breath and wheezing and productive cough, now producing yellow-brown sputum with increasing frequency, but he has had no further episodes of melena since transfer to the ICU. He is also complaining of some laryngitis and some pharyngitis, but is denying any abdominal complaints, nausea, or diarrhea.

PHYSICAL EXAMINATION
VITAL SIGNS: Blood pressure is 100/54, heart rate 80 and temperature 98.8. Is and Os negative fluid balance of 1.4 liters in the last 24 hours.
GENERAL: This is a somnolent 68-year-old male, who arouses to voice, wakes up, seems to have good appetite, has continuing cough. Pallor is improved.
EYES: Conjunctivae are now pink.
ENT: Oropharynx is clear.
CARDIOVASCULAR: Reveals distant heart tones with regular rate and rhythm.
LUNGS: Have coarse breath sounds with wheezes, rhonchi, and soft crackles in the bases.
ABDOMEN: Soft and nontender with no organomegaly appreciated.
EXTREMITIES: Showed no clubbing, cyanosis or edema. Capillary refill time is now normal in the fingertips.
NEUROLOGICAL: Cranial nerves II through XII are grossly intact with no focal neurological deficits.

LABORATORY DATA: Laboratories drawn at 1449 today, WBC 10, hemoglobin and hematocrit 11.5 and 33.1, and platelets 288,000. This is up from 8.6 and 24.7. Platelets are stable. Sodium is 134, potassium 4.0, chloride 101, bicarb 26, BUN 19, creatinine 1.0, glucose 73, calcium 8.4, INR 0.96, iron 13%, saturations 4%, TIBC 312, TSH 0.74, CEA elevated at 8.6, ferritin 27.5 and occult blood positive. EGD, final results pending per Dr. X's note and conversation with me earlier, ulcerative esophagitis without signs of active bleeding at this time.

IMPRESSION/PLAN
1. Melena secondary to ulcerative esophagitis. We will continue to monitor the patient overnight to ensure there is no further bleeding. If there are no further episodes of melena and hemoglobin is stable or unchanged in the morning, the patient will be transferred back to medical floor for continuing treatment of his chronic obstructive pulmonary disease exacerbation.
2. Chronic obstructive pulmonary disease exacerbation. The patient is doing well, taking PO. We will continue him on his oral Omnicef and azithromycin and continuing breathing treatments. We will add guaifenesin and N-acetyl-cysteine in a hope to mobilize some of his secretions. This does appear to be improving. His white count is normalized and I am hopeful we can discharge him on oral antibiotics within the next 24 to 48 hours if there are no further complications.
3. Elevated CEA. The patient will need colonoscopy on an outpatient basis. He has refused this today. We would like to encourage him to do so. Of note, the patient when he came in was on bloodless protocol, but with urging did accept the transfusion. Similarly, I am hoping that with proper counseling, the patient will consent to further examination with colonoscopy given his guaiac-positive status, elevated CEA and risk factors.
4. Anemia, normochromic normocytic with low total iron binding capacity. This appears to be anemia of chronic disease. However, this is likely some iron deficiency superimposed on top of this given his recent bleeding, with consider iron, vitamin C, folate and B12 supplementation and discharge given his history of alcoholic malnutrition and recent gastrointestinal bleeding. Total critical care time spent today discussing the case with Dr. X, examining the patient, reviewing laboratory trends, adjusting medications and counseling the patient in excess is 35 minutes.

 

[HelpPleaseMD]

you don't understand, you would still come up with a plan just say it in not so many words. And type a much shorter note

then why dont you do that instead of whine here. it is what they do in the community afterwards.

 

[sliceofbread136]

then why dont you do that instead of whine here. it is what they do in the community afterwards.

Ya man I'll strut into the room with all my med student glory, give my one sentence summary drop the mic and peace. I'm sure that would end up just super

 

[HelpPleaseMD]

sorry just not patience for whining of this sort. There is a reason academic IM notes are long. It gets shorter and shorter as you progress upwards. no shortcuts. sounds like IM is not for you. just suck it up then and be done with it

 

[sliceofbread136]

sorry just not patience for whining of this sort. There is a reason academic IM notes are long. It gets shorter and shorter as you progress upwards. no shortcuts. sounds like IM is not for you. just suck it up then and be done with it

Then gtfo the thread? I have no patience for this whining about whining

 

[BigRedBeta]

Note I wish I could write:
Patient doing well, no active bleeding per rectum, sob resolved after transfusion. Afebrile, p 80s, bp 110s/60s, 12 breaths/min, sat 96% on ra, exam benign, hgb stable at 9. Likely upper gi bleed secondary to gastritis from nsaid use, currently stable. Seen by GI, planning egd and colonoscopy in am, NPO since midnight and bowel prepped. Started iv ppi. Will continue to monitor.



Actual note:
HISTORY: Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath. Please see dictated ICU transfer note yesterday detailing the need for emergent transfer transfusion and EGD in this patient. Over the last 24 hours, the patient has received 2 units of packed red blood cells and his hematocrit and hemoglobin have returned to their baseline of approximately 11 appropriate for hemoglobin value. He also underwent EGD earlier today with Dr. X. I have discussed the case with him at length earlier this afternoon and the patient had symptoms of ulcerative esophagitis with no active bleeding. Dr. X recommended to increase the doses of his proton pump inhibitor and to avoid NSAIDs in the future. The patient today complains that he is still having issues with shortness of breath and wheezing and productive cough, now producing yellow-brown sputum with increasing frequency, but he has had no further episodes of melena since transfer to the ICU. He is also complaining of some laryngitis and some pharyngitis, but is denying any abdominal complaints, nausea, or diarrhea.

PHYSICAL EXAMINATION
VITAL SIGNS: Blood pressure is 100/54, heart rate 80 and temperature 98.8. Is and Os negative fluid balance of 1.4 liters in the last 24 hours.
GENERAL: This is a somnolent 68-year-old male, who arouses to voice, wakes up, seems to have good appetite, has continuing cough. Pallor is improved.
EYES: Conjunctivae are now pink.
ENT: Oropharynx is clear.
CARDIOVASCULAR: Reveals distant heart tones with regular rate and rhythm.
LUNGS: Have coarse breath sounds with wheezes, rhonchi, and soft crackles in the bases.
ABDOMEN: Soft and nontender with no organomegaly appreciated.
EXTREMITIES: Showed no clubbing, cyanosis or edema. Capillary refill time is now normal in the fingertips.
NEUROLOGICAL: Cranial nerves II through XII are grossly intact with no focal neurological deficits.

LABORATORY DATA: Laboratories drawn at 1449 today, WBC 10, hemoglobin and hematocrit 11.5 and 33.1, and platelets 288,000. This is up from 8.6 and 24.7. Platelets are stable. Sodium is 134, potassium 4.0, chloride 101, bicarb 26, BUN 19, creatinine 1.0, glucose 73, calcium 8.4, INR 0.96, iron 13%, saturations 4%, TIBC 312, TSH 0.74, CEA elevated at 8.6, ferritin 27.5 and occult blood positive. EGD, final results pending per Dr. X's note and conversation with me earlier, ulcerative esophagitis without signs of active bleeding at this time.

IMPRESSION/PLAN
1. Melena secondary to ulcerative esophagitis. We will continue to monitor the patient overnight to ensure there is no further bleeding. If there are no further episodes of melena and hemoglobin is stable or unchanged in the morning, the patient will be transferred back to medical floor for continuing treatment of his chronic obstructive pulmonary disease exacerbation.
2. Chronic obstructive pulmonary disease exacerbation. The patient is doing well, taking PO. We will continue him on his oral Omnicef and azithromycin and continuing breathing treatments. We will add guaifenesin and N-acetyl-cysteine in a hope to mobilize some of his secretions. This does appear to be improving. His white count is normalized and I am hopeful we can discharge him on oral antibiotics within the next 24 to 48 hours if there are no further complications.
3. Elevated CEA. The patient will need colonoscopy on an outpatient basis. He has refused this today. We would like to encourage him to do so. Of note, the patient when he came in was on bloodless protocol, but with urging did accept the transfusion. Similarly, I am hoping that with proper counseling, the patient will consent to further examination with colonoscopy given his guaiac-positive status, elevated CEA and risk factors.
4. Anemia, normochromic normocytic with low total iron binding capacity. This appears to be anemia of chronic disease. However, this is likely some iron deficiency superimposed on top of this given his recent bleeding, with consider iron, vitamin C, folate and B12 supplementation and discharge given his history of alcoholic malnutrition and recent gastrointestinal bleeding. Total critical care time spent today discussing the case with Dr. X, examining the patient, reviewing laboratory trends, adjusting medications and counseling the patient in excess is 35 minutes.

There's a middle ground in between those two. For starters, there's no need to use complete sentences, and anyone who says otherwise should go be a HS English teacher and quit walking around the hospital with a stick up their hindparts.

Second, if you get good at it, dictating your notes is the way to go if you still like having all those words or you're OCD that your notes have to be "complete".

Third, notes in academic medicine are the equivalent of showing your work on long division problems in 4th grade. Students and interns need to be more in depth so that those above them can see the way in which they make decisions. Once you get out of those junior roles, the rules should be loosened, and you can say "titrate mechanical ventilation per sats and serial blood gasses" vs "wean PEEP to 9 for sats >88% if FiO2 remains <0.4, monitor for derecruitment 10-12 hour after wean, decrease PIP's by 2 to maintain tidal volumes 6-8ml/kg as pulmonary compliance improves". The first is accurate and does enough for the lawyers, but tells me, your ICU attending, nothing about your grasp of the physiology. If you show me you know it, I don't have to waste your time (or mine) teaching it to you again and we can discuss more interesting things.

 

[atomi]

If you're spending most of your day writing soap notes, you're doing something wrong. They should only take a few minutes a piece.

 

[jdh71]

It's mostly billing. Your note needs the appropriate information to bill for the visit at the amount that makes it worth your time. Also standardizing the information helps with communication. Finally whatever you put in the medical record is basically the final say from a legal perspective - if you get sued and haven't documented your side of the story, your dude of the story doesn't exist.

Procedural fields can get away with a lot less given the bundled reimbursement. Though even then, if you want to also get paid for your consult and you probably should since touvarthe doing the heavy thinking lifting and taking the medical legal liability then you will need the required info.

 

[group_theory]

IMPRESSION/PLAN
1. Melena secondary to ulcerative esophagitis. We will continue to monitor the patient overnight to ensure there is no further bleeding. If there are no further episodes of melena and hemoglobin is stable or unchanged in the morning, the patient will be transferred back to medical floor for continuing treatment of his chronic obstructive pulmonary disease exacerbation.
2. Chronic obstructive pulmonary disease exacerbation. The patient is doing well, taking PO. We will continue him on his oral Omnicef and azithromycin and continuing breathing treatments. We will add guaifenesin and N-acetyl-cysteine in a hope to mobilize some of his secretions. This does appear to be improving. His white count is normalized and I am hopeful we can discharge him on oral antibiotics within the next 24 to 48 hours if there are no further complications.
3. Elevated CEA. The patient will need colonoscopy on an outpatient basis. He has refused this today. We would like to encourage him to do so. Of note, the patient when he came in was on bloodless protocol, but with urging did accept the transfusion. Similarly, I am hoping that with proper counseling, the patient will consent to further examination with colonoscopy given his guaiac-positive status, elevated CEA and risk factors.
4. Anemia, normochromic normocytic with low total iron binding capacity. This appears to be anemia of chronic disease. However, this is likely some iron deficiency superimposed on top of this given his recent bleeding, with consider iron, vitamin C, folate and B12 supplementation and discharge given his history of alcoholic malnutrition and recent gastrointestinal bleeding. Total critical care time spent today discussing the case with Dr. X, examining the patient, reviewing laboratory trends, adjusting medications and counseling the patient in excess is 35 minutes.

Actually if you write this note, if your attending does not clarify, you will get a coder query from a hospital coder (or "clinical documentation specialist") since you didn't say the magic words ... so you and your hospital will not be paid according to severity of illness

Plus the above note doesn't support critical care time. It would be a 99233 (inpatient hospital follow-up, level 3). Even then, the time the student/resident/fellow spent doesn't count. It's the attending time that counts. So a resident or fellow putting that statement in doesn't do anything, the attending must attest to the time. But from the above note, the patient doesn't meet criteria to support critical care time, even if the patient is still physically in the ICU

To make the coders happy while CYA:


Agree with note as written above with the following attending statement:

Impression/Plan
1. Acute Blood Loss Anemia, upper GI source - improved with transfusion. Getting EGD in AM. NPO p midnight.
2. Acute exacerbation of COPD, emphysematous type, subsequent encounter - doing well with RTC nebs and abx. Add guaifenesin and NAC. Continue IV abx since NPO. switch to PO when able. Smoking cessation counseling provided - patient declined.
3. Elevated CEA - needs colonoscopy, patient refused. Informed patient of rationale for colonoscopy, which includes colon cancer, and reason for scope. Continues to refuse.
4. Anemia, multifactorial - anemia of chronic disease +/- iron deficiency. Start MVI. Recommend colonoscopy - patient refuses.
5. protein caloric malnutrition from alcoholism - no evidence of DT. Electrolytes replaced. Currently NPO. Watch for refeeding when eating.

Transfer to medicine. ICU service will sign off. (sorry, force of habit )

 

[jdh71]

Actually if you write this note, if your attending does not clarify, you will get a coder query from a hospital coder (or "clinical documentation specialist") since you didn't say the magic words ... so you and your hospital will not be paid according to severity of illness

Plus the above note doesn't support critical care time. It would be a 99233 (inpatient hospital follow-up, level 3). Even then, the time the student/resident/fellow spent doesn't count. It's the attending time that counts. So a resident or fellow putting that statement in doesn't do anything, the attending must attest to the time. But from the above note, the patient doesn't meet criteria to support critical care time, even if the patient is still physically in the ICU

To make the coders happy while CYA:


Agree with note as written above with the following attending statement:

Impression/Plan
1. Acute Blood Loss Anemia, upper GI source - improved with transfusion. Getting EGD in AM. NPO p midnight.
2. Acute exacerbation of COPD, emphysematous type, subsequent encounter - doing well with RTC nebs and abx. Add guaifenesin and NAC. Continue IV abx since NPO. switch to PO when able. Smoking cessation counseling provided - patient declined.
3. Elevated CEA - needs colonoscopy, patient refused. Informed patient of rationale for colonoscopy, which includes colon cancer, and reason for scope. Continues to refuse.
4. Anemia, multifactorial - anemia of chronic disease +/- iron deficiency. Start MVI. Recommend colonoscopy - patient refuses.
5. protein caloric malnutrition from alcoholism - no evidence of DT. Electrolytes replaced. Currently NPO. Watch for refeeding when eating.

Transfer to medicine. ICU service will sign off. (sorry, force of habit )

Coders still won't be happy with that note until you specify the severity the of protein calorie malnutrition

 

[KnuxNole]

Note I wish I could write:
Patient doing well, no active bleeding per rectum, sob resolved after transfusion. Afebrile, p 80s, bp 110s/60s, 12 breaths/min, sat 96% on ra, exam benign, hgb stable at 9. Likely upper gi bleed secondary to gastritis from nsaid use, currently stable. Seen by GI, planning egd and colonoscopy in am, NPO since midnight and bowel prepped. Started iv ppi. Will continue to monitor.



Actual note:
HISTORY: Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath. Please see dictated ICU transfer note yesterday detailing the need for emergent transfer transfusion and EGD in this patient. Over the last 24 hours, the patient has received 2 units of packed red blood cells and his hematocrit and hemoglobin have returned to their baseline of approximately 11 appropriate for hemoglobin value. He also underwent EGD earlier today with Dr. X. I have discussed the case with him at length earlier this afternoon and the patient had symptoms of ulcerative esophagitis with no active bleeding. Dr. X recommended to increase the doses of his proton pump inhibitor and to avoid NSAIDs in the future. The patient today complains that he is still having issues with shortness of breath and wheezing and productive cough, now producing yellow-brown sputum with increasing frequency, but he has had no further episodes of melena since transfer to the ICU. He is also complaining of some laryngitis and some pharyngitis, but is denying any abdominal complaints, nausea, or diarrhea.

PHYSICAL EXAMINATION
VITAL SIGNS: Blood pressure is 100/54, heart rate 80 and temperature 98.8. Is and Os negative fluid balance of 1.4 liters in the last 24 hours.
GENERAL: This is a somnolent 68-year-old male, who arouses to voice, wakes up, seems to have good appetite, has continuing cough. Pallor is improved.
EYES: Conjunctivae are now pink.
ENT: Oropharynx is clear.
CARDIOVASCULAR: Reveals distant heart tones with regular rate and rhythm.
LUNGS: Have coarse breath sounds with wheezes, rhonchi, and soft crackles in the bases.
ABDOMEN: Soft and nontender with no organomegaly appreciated.
EXTREMITIES: Showed no clubbing, cyanosis or edema. Capillary refill time is now normal in the fingertips.
NEUROLOGICAL: Cranial nerves II through XII are grossly intact with no focal neurological deficits.

LABORATORY DATA: Laboratories drawn at 1449 today, WBC 10, hemoglobin and hematocrit 11.5 and 33.1, and platelets 288,000. This is up from 8.6 and 24.7. Platelets are stable. Sodium is 134, potassium 4.0, chloride 101, bicarb 26, BUN 19, creatinine 1.0, glucose 73, calcium 8.4, INR 0.96, iron 13%, saturations 4%, TIBC 312, TSH 0.74, CEA elevated at 8.6, ferritin 27.5 and occult blood positive. EGD, final results pending per Dr. X's note and conversation with me earlier, ulcerative esophagitis without signs of active bleeding at this time.

IMPRESSION/PLAN
1. Melena secondary to ulcerative esophagitis. We will continue to monitor the patient overnight to ensure there is no further bleeding. If there are no further episodes of melena and hemoglobin is stable or unchanged in the morning, the patient will be transferred back to medical floor for continuing treatment of his chronic obstructive pulmonary disease exacerbation.
2. Chronic obstructive pulmonary disease exacerbation. The patient is doing well, taking PO. We will continue him on his oral Omnicef and azithromycin and continuing breathing treatments. We will add guaifenesin and N-acetyl-cysteine in a hope to mobilize some of his secretions. This does appear to be improving. His white count is normalized and I am hopeful we can discharge him on oral antibiotics within the next 24 to 48 hours if there are no further complications.
3. Elevated CEA. The patient will need colonoscopy on an outpatient basis. He has refused this today. We would like to encourage him to do so. Of note, the patient when he came in was on bloodless protocol, but with urging did accept the transfusion. Similarly, I am hoping that with proper counseling, the patient will consent to further examination with colonoscopy given his guaiac-positive status, elevated CEA and risk factors.
4. Anemia, normochromic normocytic with low total iron binding capacity. This appears to be anemia of chronic disease. However, this is likely some iron deficiency superimposed on top of this given his recent bleeding, with consider iron, vitamin C, folate and B12 supplementation and discharge given his history of alcoholic malnutrition and recent gastrointestinal bleeding. Total critical care time spent today discussing the case with Dr. X, examining the patient, reviewing laboratory trends, adjusting medications and counseling the patient in excess is 35 minutes.

My notes now are more like the first one....

 

[Raryn]

Your first note is too short if you're a medical service, and your second is appropriate for a student note, but way longer than someone through training would write. I'm closer to group_theory with notewriting, though I'm a big fan of bullets rather than sentences.

As for the discussion above regarding two minute notes... Most students don't understand why surgeons can get away with writing two line notes. It's not because surgeons are so much smarter (or dumber, depending on who's telling the story) than internists... It's a symptom of how billing works. To summarize in relatively general terms:

If a patient gets an operation, everything the surgeon does before and for up to 90 days (length depending on complexity) after that operation, including all pre-op, intra-op, and post-op care is generally covered under a "global fee". Document 5000 problems daily or 1 problem, it's still all part and parcel of care for your patient and pays zero on top of the fee for the surgery itself. So why on earth would a surgeon write more than the absolute bare minimum to avoid lawsuits on any post-op patients? I've seen patients on the primary CT surgery service get four line notes for days on end when serious things are changing clinically, which you'd never pick up on if it wasn't for notes from some other service. Initial consultations pay a bit more (and are more important) so those are usually closer to what other consultants write.

On the other hand, everyone not doing operations (or surgeons on non-operative patients) is paid based on complexity (with a much smaller component based on time thats much larger if you happen to have patients that are critically ill). For some strange reason, insurance companies won't believe you if you just write "this is a very complex patient", so you have to actually document all of the required elements of the history/physical/medical decisionmaking in order to accurately convey the complexity of your patients. This leads to longer notes.

Of course, on top of that, there's a bunch of inane ways people have figured out how to game the system (documenting specific nutritional statuses for every patient for example) and that the "diagnoses" recognized by billing/coding are frequently far removed from reality (compared to just freehand writing a diagnosis!, so we give up clarity of notes in order to maximize our billing. If you're skilled and still give a damn, you can still write a good note under those circumstances, but far more often it comes out like a bunch of nonsense. But it's a symptom of the system we're in, not because internists are so much (insert describitor of choice here) than surgeons.