Erica Remer, MD, CCDS, a Member Board of Directors of American College of Physician Advisors, have been talking about improving the electronic medical record and making it more end-user-friendly. Today, she grouses about documentation in general.
Her husband, who is a radiologist, and she were commiserating at how awful and uninformative provider documentation has become since they started practicing medicine in the 1980s. In the handwritten days, the story was better; it was just often illegible. But people didn’t waste copious chart real estate on useless rehashing of details which weren’t helpful even the first time they were introduced into the record.
She shares with us some of her biggest pet peeves and tell providers how not to include these in their documentation.
Whoever tells it was good practice to put a laundry list of prior medical history into the first sentence (e.g., “This is a 75-year-old male with hx of HTN, HLD, DM, CAD with multiple PCIs and stents, ICM with EF 25%, OSA, polymyositis, COPD, and CKD with right wrist pain”) was wrong! It is useful to set the table with past medical history which might be relevant, like if the chief complaint for that patient was shortness of breath, cardiac and pulmonary conditions might be helpful, but otherwise, it is just noise.
- Set the table with pertinent conditions that potentially relate to the chief complaint
- Pertinent negatives can be useful, too (e.g., The patient does not have diabetes)
And while she is looking at that example, alphabet soup is lazy and can be misleading. Unless using the medical abbreviations approved within the organization, using letters which have ambiguous meanings. Another oncologist may understand what his colleague was referring to, but a nephrologist, surgeon, or nurse may not recognize that particular set of letters. She spent a whole day deciphering a single obstetrical record when she was a physician advisor, because it had been 20 years since she rotated through OB.
- Only use approved abbreviations
- Better yet, create acronym expansions so that it can be type “HLD” and out comes hyperlipidemia.
It is exasperating for entire chunks of the HPI to be elucidating the previous admission. It is often impossible to tell what happened last time and what the patient/family is complaining about happening now which caused today’s encounter. It is compounded by that same paragraph being copy and pasted and repeated every single day following, in every single progress note.
- If you are interested in including the details of the previous encounter, succinctly SUMMARIZE them into a few sentences and CLEARLY identify them as being from the previous encounter (e.g., The patient was discharged 1 week ago after an admission for similar abdominal pain and vomiting which was felt to be due to cholelithiasis as was demonstrated on ultrasound.”)
- Please don’t forget to include why the patient is here today! It is not uncommon for her to see paragraphs about the previous encounter and known medical history and then there are no details on why the patient presented TODAY. This is so unhelpful!
- She had a situation in which a coder asked her what to do about a procedure which had actually been performed on the previous admission but was copy and pasted into this encounter. All of a sudden, the record was declaring, “Post-op Day 2,” “Post-op Day 3.” This is not only misleading and confusing, but it could be construed as fraud if the coder hadn’t noticed it and she had billed for it again on this admission.
Speaking of that practice, STOP COPY AND PASTING! She says. HATE reading other peoples’ copy and paste because it isn’t helpful. In fact, it can be detrimental by obscuring or obfuscating important details. She knows it is easy, but it isn’t advancing the story. The reality is that were never supposed to reiterate the same history of present illness day after day; you were always supposed to be presenting the interval history detailing what was going on with the patient today. If someone needs to see what happened on admission, they can go to the H&P and read it there.
For example, she kept seeing providers copy and pasting, “Blood culture possible contaminant strep intermedius,” and eventually eked out the infectious disease consultant’s opinion that, “I do not think Strep. Intermedius represents a contaminant; I think it is pathogenic.” But people kept perpetuating the contaminant fairy tale, even in the discharge summary. It took a tremendous amount of investigating to find the truth.
- STOP COPY AND PASTING! (she just copy and pasted this, for emphasis!)
- She doesn’t need to see the reason the patient presented to the ED, on day 5. She DOES need to see what is going on now. Stop, think about the patient and the longitudinal story, and document THAT.
Now that the provider is going to get paid according to their medical decision making, they had better start providing evidence that they are actively making decisions. If all they do is copy and paste the previous assessment and plan (without edit), it isn’t clear that they thought about the patient at all today. If symptoms have given rise to definitive diagnoses, retire the symptoms in your impression list and replace them with the diagnosis. As you accrue new data, have your diagnosis become more robust.
- Evolve, resolve, remove (recap). Have uncertain diagnoses give way to certainty as more data becomes available. As conditions resolve or are ruled out, have the documentation reflect that.
- Make diagnoses. Link symptoms to diagnoses. Link conditions to etiologies (e.g., acute blood loss anemia due to angiodysplasia compounded by coagulopathy due to warfarin)
Be accurate. Be specific. Is it a random leg cellulitis or is it an infected venous harvest graft site with surrounding cellulitis? If a patient has acute on chronic hypoxic respiratory failure in the context of an exacerbation of advanced COPD, don’t call it acute hypoxic respiratory failure.
- It may be an hASSLe, but attend to Acuity, Severity, Specificity, and Linkage.
- She saw a case in which there was a “nonocclusive thrombus” in the right femoral vein which turned out to be likely scar tissue from an old deep venous thrombosis from three years prior. Everyone kept copy and pasting the same radiology result without evolving the diagnosis into an “old DVT.” The patient was discharged on anticoagulation and came back with a massive gastrointestinal hemorrhage.
Don’t just import radiological reports, even the impressions, without giving the clinical significance.
- She can’t code from radiological reports on the inpatient side, even if they embed her in their document. Only a provider with clinical responsibility for the patient may make codable diagnoses.
- The imaging may indicate a different diagnosis than what is being propagating with your excessive copy and paste (e.g., I saw a case of a pelvic CT which demonstrated “a fluid collection” which was drained and grew out Enterococcus, but no one ever called it a pelvic abscess, so pelvic abscess wasn’t coded. If the patient returns, it may not be picked up that they had that pelvic abscess if you didn’t ever say it!).
Make your discharge summary count. Did I mention DON’T JUST COPY AND PASTE the same narrative into the discharge summary?! Don’t bring the entire HPI from the H&P into the discharge summary. For the follow up provider or if the patient presents to the ED, a cogent chronicling of the admission can be the difference between a good and bad outcome.
- It is fine to have a sentence or two about why the patient presented originally, but then give the account of the encounter with the important diagnoses, procedures, and findings laid out in a chronological and logical fashion.
- This is the “recap” of Evolve, Resolve, Remove, Recap. All- important diagnoses should reappear in the discharge summary, fleshing out the stay. Many a denial has been predicated on the loss or dilution of a diagnosis (“well, if the patient was really septic on admission, why didn’t they mention it in the discharge summary?”) or back tracking (e.g., acute hypoxic respiratory failure documented from Days 1-3 becomes downgraded to “hypoxia” in the discharge summary).
When you read someone else’s documentation, aren’t there behaviors that drive them mad? Don’t do THEM to other people! Documentation isn’t a burden; it is a responsibility. In fact, the burdensome parts of documentation have actually now been removed (like doing a review of systems on everyone) and left you with the useful part of the storytelling. Make your documentation tell a story that makes sense to the reader. This is not for the payer or even the lawyer; it is imperative to take excellent care of your patients
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