Blog | Thursday, October 10, 2013

The movement to improve patient notes


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, MD, FACP, 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?

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.