Blog | Thursday, October 3, 2013

The patient note is the biggest problem in medicine today


I spent a day 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 electronic health records 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.

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.