Blog | Tuesday, February 5, 2013

Progress notes are a poor match between billing and medical information

We had a delightful dinner with a medical couple. He (the neurologist) started raving about electronic medical records (EMRs) and the lousy notes they created.

EMRs have problems, but we really should not blame the current state of uninformative progress notes on the EMR. Rather we should blame the bureaucrats who developed billing criteria.

This is not a new subject for this blog, but I would like to take a slightly different take.

What is the historical purpose of the medical note? We write notes so that we can state our thought process and make clear our plans. I want to read my consultant notes and understand clearly and succinctly what they recommend and why. I want them to read my note and understand my thought process so that they can reflect and suggest other possibilities.

In the 1970s, I was taught to write notes that conveyed my assessment and plans. I would include minimal subjective and objective data, just those data necessary to document.

In this century, our notes are written to pass muster from billing clerks. We must document enough physical examination points and systems review points to fit their billing code.

Too often the EMR note builders focus on the latter rather than the former. Too often physicians cut-and-paste large amounts of data, and then shortchange the assessment and plan.

Our problem comes from a misunderstanding from the billing perspective. Medical progress notes have a very important rationale. We need readable notes. We need informative notes, not pages worth of billing information.

This is not just the rant of an old codger wishing for the good old days. Rather, I am reflecting on a common sentiment.

When I have reviewed malpractice cases, the notes are painful to study. Rarely do they provide a window into the thought process. But they are accurate billing records.

I am certain that Medicare and the insurance companies do not consider the unintended consequences of our documentation rules.

I doubt that they understand that these requirements have a negative influence on patient care. We have a misfit between our notes and communication. This is not good for patient care.

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.