The new interns are here, the new interns are here!
With a week of global residency orientation under their belts, and an entire morning of orientation at our practice on the nuts and bolts of seeing patients in the outpatient world, the first group of our new class of interns has started on their ambulatory rotations. Everybody seems really enthusiastic and excited to be here, ready to take on healthcare and all the challenges that come with it as we fight the good fight to take care of our patients.
They’ve all had long sessions in training with our electronic health record (EHR), and many of them in fact have used the same one at their prior institutions, working on the wards or in clinics as medical students. We are hoping that moving forward we can instill in them a desire to create a better medical record, to learn to write a note that reflects what really happened in our practice, and all the effort we put into trying to take care of our patients.
Just this morning, with a number of new patients on their schedules as well as some follow-up appointments, we reviewed the processes of pre-charting, reviewing old notes, looking at recent labs and consult notes, reviewing admissions and discharge summaries, updating medication lists, and so much more.
One complicated patient we saw had a recent visit with a specialist after they were sent home from the hospital, and we opened up their note to see what they had thought and what action they recommended that the patient take. It was 37 pages long.
I know, these aren’t actual pages, since we didn’t print out the note, but we clicked through 37 screenfuls of information on the computer monitor from the patient’s hospital course and past medical history. Screen after screen of labs, cut and pasted data from imaging and procedures and prior consult notes — on and on it went. But even reading through it in detail, we never really got a sense of what this provider was thinking, and what they thought should happen next.
Taking the 30,000 foot view (how did we decide on this height – is cruising altitude for an airliner really where we can see the big picture?), we were able to see that they incorporated multiple old notes that included what other providers had decided to do, probably in an effort to collate and summarize what all of the plans had been.
Unfortunately, each of these started out with something along the lines of “So for today’s visit…” So as we read along, we kept thinking that we were finally coming across the assessment and plan. But in fact, when we got to the very end, we realized we still had no idea what the next steps should be for this patient.
Many of our colleagues have started moving the assessment and plan up to the top of their notes, since I think they have found that that’s really all everyone’s looking for, all they are reading — what they think is going on, and what they recommend.
We are standing at a time when great opportunity has presented itself, because the January 2021 changes to the Medicare billing and coding compliance guidelines have eliminated an enormous amount of unnecessary documentation from being required in office notes. No longer are the billing and compliance auditors going to be reviewing our charts and counting up the number of organ systems reviewed, the details in each complaint in the history of present illness, or whether a particular field was clicked as reviewed.
The decision was made — and we think it was long overdue — to let the level of service be almost entirely driven by the level of medical decision-making: the number of problems addressed, the medical complexity, the risk to the patient. This is how we thought it should be all along, and it has been incredibly refreshing to see the change come about at last.
It has definitely been hard for providers to transition to this new system, and I think our instincts are still to copy forward, cut and paste, and include everything. I think the time has come for this all to become unnecessary, for us to build the electronic medical record as a repository for each patient’s healthcare journey, but not require any longer that we pull every old detail, into each and every note we write. With the popularity of the Open Notes movement, and the fact that our patients are going to be reading and reviewing more and more of the notes we write about them, it makes sense that we focus on clarity, brevity, truth-telling, and communication. The echocardiogram report is right there in the same electronic medical record; I don’t need to copy it into my note.
As we all begin to relearn the art of documentation in the electronic medical record, I think we should encourage and reward the new generation of physicians coming up, give them useful tips, and certainly no longer punish them for not having page after page of unnecessary detail. When we link our note to theirs, we can similarly link our note to all the other content contained within the electronic medical record, and even in outside records which we can reference.
So think about it: think how you plan to change your note-writing, and think how we can change how we teach this brand new generation of doctors to take care of people and take care of the charts, and take care of themselves.
Let me know, in the comments section below, if you have additional ideas on how to build a better, smarter, medical record that makes sense for everyone.
Duly noted.
Fred N. Pelzman, MD, of Weill Cornell Internal Medicine Associates and weekly blogger for MedPage Today, follows what’s going on in the world of primary care medicine from the perspective of his own practice.
Last Updated June 23, 2021
Source: MedicalNewsToday.com
