Blog | Thursday, August 29, 2013

We should require meaningful notes


I had a nice conversation with a dermatologist at party last night. He started complaining about the notes he receives from other physicians. He used terms like "piles and piles of junk."

Talk to any experienced physician and they will tell you that once upon a time our teachers taught us to write notes appropriate to the situation, not appropriate to the billing system.

Several years ago I ranted about the necessity for coding experts. What does that have to do with good medical care?

In 1973 we were taught to write SOAP notes. SOAP notes served me and my patients well throughout my internship, residency, and early years in outpatient practice. What happened? With the introduction of resource-based relative-value units, bureaucrats had the opportunity to make rules about what constituted a level 1, 2, 3, 4 or 5 note. Thomas Sowell stated succinctly, "You will never understand bureaucracies until you understand that for bureaucrats procedure is everything and outcomes are nothing." The bureaucrats came up with a plan for documentation that shows a total lack of understanding of medicine.

Electronic medical records have made this worse. Now we have institutionalized bad notes. And bad notes harm patient care.

Physicians now spend too much sorting through the haystack of notes that document unnecessary 12-point review of systems, and repeated complete physical exams when they are totally unnecessary. We see note after note repeating all the laboratory data.

The problem here is that the physician note writer is not involved in figuring out what data are important. Our current notes are mindless. They do not reflect our thought processes.

When we were taught about SOAP notes, they went like this:
1) Write a separate SOAP note for each problem, either a diagnosis or a complaint.
2) For each problem include first the subjective data related to that problem.
3) Then include the objective data, physical exam, relevant lab data and imaging.
4) Then include your analysis. This section reflects your current thought process.
5) Finally, include the current plan: lab tests, medications, surgical consult, etc.

We need to know what our colleagues are thinking. We need to review our students and residents thought processes. Notes written like this require thinking, thinking about what are the relevant data and how one evaluates the data.

I believe that such notes help us think more clearly about our patients. They clearly make it easier for other physicians to review our notes and thought processes.

We must demand that we return to meaningful notes. We must let everyone know our outrage over cut and paste notes, data overload notes, and non-thinking notes. Our patients deserve understandable notes. Unfortunately, today we have horrible notes, and we are not teaching our students and residents to think, partly because of the notes they must write for billing purposes only.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.