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The patient note is the biggest problem in medicine today.

[Note: These two posts are reprinted, with permission, from Dr. Robert M. Centor’s db’s Medical Rants]

The patient note is the biggest problem in medicine today

by RCENTOR on AUGUST 30, 2013

I spent yesterday at Hennepin County Hospital in Minneapolis. During lunch, we had a discussion about the thought process of internal medicine, and how we should teach thinking. Not surprisingly, attention turned to the patient note. The teachers in the audience bemoaned the degradation of the patient note.

We need a mission. We need to resuscitate the patient note. We need meaningful, readable, informative patient notes.

A previous rant recently ran on KevinMD – We need to reassess the patient note.

One comment challenged me as an ACP leader to have the organization address this issue.

Without revealing too much, let me assure readers that ACP has made administrative burdens the key policy issue this year.

Our notes have degenerated to satisfy billing requirements. Our EHRs are written primarily to satisfy billing requirements.

We need clinicians (that term used rather than physicians, because not all physicians do enough clinical work to be clinicians) to state the standards for good patient notes. We need real analyses and plans that every other physician can interpret and understand.

We do not need daily physical exams, except for the relevant systems. We do not need daily review of systems, rather just an updated history of the active problems and the answer to the open ended question about new complaints.

We should reclaim the patient note. I would prefer that we return to Larry Weed’s original SOAP notes. Each problem had a subjective, an objective, an assessment and a plan. As I wrote those notes, the pieces congealed into a larger whole. We should unite to object against notes designed for billing. And we should probably outlaw cut and paste.

The movement to improve patient notes


Last week I tweeted about my recent posts on the patient note. This week I will continue trying to stimulate a movement and have bloggers and tweeters join that movement.

My friend and former Chair of ACP’s Board of Regents, Yul Ejnes, wrote a wonderful piece recently – English is the second language of medical documentation.

It is time for an “English First” movement for medical documentation. Call it “Leave No Narrative Behind” or something equally catchy. Let’s defend the medical record from the compliance officers, insurance companies, lawyers, regulators, accreditors, and EHR vendors. Let’s exile the “ten-point review of systems” to the auto repair shop!

That’s why the American College of Physicians recently approved a resolution that “endorses and actively promotes documentation within the electronic medical record (EMR) to improve communication that emphasizes the thought process underlying decision making, patient complexity, and medical necessity with clarity and without requiring repetition of past notes, tests and extraneous data.”

One of the most liberating things that I’ve done in a while is to use voice recognition software with my EHR. Instead of clicking boxes to generate a “Med Lib” supplemented by hastily typed short phrases, I now dictate a paragraph or two for the HPI, the review of systems, and the examination, and I document as thorough an assessment and plan as I did in the days that we documented in English. Someone can read my notes and know what I did, and more importantly, what I was thinking. That still doesn’t cure the systemic illness of billing needs trumping clinical needs in medical documentation. But it’s a start.

Yul has helped start the movement. Will you please blog and tweet about this movement?  We have many physicians involved in social media. If social media has power, we should use that power. Or do you like the notes that you find in charts and referral letters?

So, what do you think?

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