It’s always kind of a surprise when you read a patient’s chart, and you see an examination of a body part they just don’t have.
Just the other day, I was reading a consult note on a patient of mine who had been seen by a subspecialist for evaluation of a serious issue, and I received back a long detailed office note with an extensive history of present illness (HPI), full details of his past medical history, all the interventions that had been tried in the past, and an endless string of labs and imaging tests. And, finally, a physical examination.
What was most striking was that this patient had multiple things documented as being present and normal, when they just were not. For example, his extremities exam revealed 2+ distal pulses, with brisk Achilles tendon reflexes, with full range of motion of his ankle joints without pain. But he had bilateral above-the-knee amputations over 20 years ago.
His skin was described as warm and well perfused, without lesions or rashes, despite the fact that he has chronic weeping lesions from an advanced connective tissue disease that has plagued him most of his adult life. And, most interestingly, his head was described as normocephalic and atraumatic, despite the fact that it is definitely not.
A More Perfect Medical Record
On the whole, the specialist took outstanding care of the patient, and ultimately communicated to me his plan, which was incredibly thoughtful and on-target, and turned out to offer some critical treatment options that proved very effective for the patient. But when I look back on this massive note, there’s so much noise, so much excessive clicking, so much of a drive by all of us to fill in all the boxes, that the most important information is almost lost.
Some providers cut-and-paste and copy forward every single office visit they’ve ever had with a patient, and then add on an invocation like “today’s update”: and then type in what’s changed clinically, how the patient is feeling today, and then their plan.
Perhaps as these electronic medical records get more sophisticated, we can think about ways to improve what we use them for, how we use them, and why we have this compelling need to flesh out the history and examination and spill back onto the page everything we’ve ever learned about this patient.
My suggestion is that we start to think of the electronic medical record as a central repository, a place where the patient lives in a patient-centered way, their medical history representing them, and all of the rest of us, the caregivers who interact with him, put down only what we really need to talk about to get our point across.
We all trained writing SOAP notes, and the concept of putting all the details, every possible scrap of data down, has always seemed like something that was important to do. Remember writing in the labs by hand in those fishbone grids for CBC and electrolytes and the rest of the labs? But why not re-think this; why not let the electronic medical record become the place where all the members of the care team can touch the chart of this patient, offer some advice and insight, and then move on?
Billing Document or Patient History?
So much of this has encumbered us as we battled to create a billing and compliance document, knowing that we won’t be paid enough unless we have a detailed HPI, a complete past medical, surgical, social, and family history.
Just recently, we’ve been told that we are no longer allowed to say “Review of Systems negative,” but we now have to say “10+ Review of Systems negative except as a detailed above,” or else we won’t get credit for all those different systems.
The auditors who are looking over our charts are counting up all of the different elements of all of the different parts of our documentation, and then deciding how much to pay us for the care we provide.
We’ve allowed the cart to pull the pony, and we’ve all gotten on board for the ride.
While documentation for medical necessity, and medicolegal purposes, is clearly always going to be a part of this, it feels like we need to get back to allowing the medical record to become a place where we render an opinion, where we collect our thoughts, where we synthesize the data, where we put our plan into action.
I remember when I first joined our practice, and I took over a panel of patients from a physician who was retiring from clinical work, and I started seeing all of these established patients, each one accompanied by a thick paper chart.
In those days the past medical history, medications, allergies, and all the rest were filled in on separate multicolored sheets attached to the front of the chart, and rarely were these kept up-to-date. Sure, there was a big red sticker flag for “Penicillin Allergy,” but often everything else was sort of lackluster and haphazardly filled in.
When I would see one of these patients in the office, and once the paper chart was retrieved from the Medical Records storeroom, I would start digging around to find out what was going on.
I remember my first office visit with one of her most complicated patients where I paged through the chart to review her most recent notes: “Feeling well. Lungs clear. Continue current regimen.” That was it. Not the level of detail that you’d actually want to have to help you know what was going on, what had happened, what the plan actually was, but maybe that was really all that had been going on that day.
Finding Something In Between
I think we need to find something between this cryptic, telegraphic, can’t-you-figure-out-what-I’m-thinking kind of chart work, and the overwhelming electronic diarrhea that we have now allowed the systems to create with a few simple clicks of some buttons.
As electronic medical records get more sophisticated, and we begin to combine data sources from multiple providers all over the country into a unified electronic record, perhaps we can find a way to standardize what we keep, and what happens on the periphery.
We need to start thinking about electronic medical record restraint, limiting us to just what is needed to render a professional opinion about what’s going on in this patient today. “Here is their neurologic history and exam as I elicited it today; this is what I think should be the next step.” “I examined their skin and think this is psoriasis.” “Their diabetes is not well controlled; I recommend going up on their basal insulin dose.”
Just because the electronic medical record can document everything all the time doesn’t mean that we have to, or that we should, or that clicking all those buttons and generating all those words on the page will really provide better care for our patients. True, it may allow us to get to a higher level of billing, but we have to refocus on making sure that we use these new tools to really improve the lives of our patients, as well as the lives of the doctors trying to take care of them.
I’ve said enough.