Restoring the Story and Creating a Valuable Clinical Note

I could not agree with the author more. Having grown up in the pre EMR era I long for the narrative note. I never could fully embrace the templated note or the idea of documenting to justify my charges. We need to end the tyranny of overdocumentation.

Disclosures:

No Conflict of Interest

This is such an important article an issue for all of us who care for patients. The authors point out the shortcomings of the cut and paste notes that were designed to fulfill billing requirements, but don’t include the patient’s voice or  preferences and critical integration of data to formulate a diagnosis and plan. There have been numerous examples of diagnostic error that resulted from misleading or erroneous information that was copied and pasted from visits that no longer apply to the patient’s current status. My gratitude to the authors of this article for spearheading this important initiative that we need to incorporate into our daily practice.

One further harm from modern notes is that in signing them we accept, and model to learners, the tacit acceptance of casual fraud. This is mentioned in passing by the authors who observe that, although a note may state that cranial nerves II-XII are normal, there’s no reason to believe these were tested (especially for a progress note, especially when cut-and-pasted). Acknowledging that olfaction was not evaluated seems to suggest a fig leaf’s worth of virtue.  The same is true, I’m pretty sure, for the “12-system review of symptoms” that may be recorded daily. My guess is that most authors couldn’t name 12 systems.

The amount of note bloat leads to a missing the forest for the trees mentality.  Personally, I have found that when dictating an assessment & plan, I much more effusive and provide a better narrative than when I am typing in a problem list. Many of us are not expert keyboarders, and as such, we tend to take shortcuts about a patient’s narrative.   Using an APSO note format, also allows both the reader and the author to focus on the assessment and plan, and then draw a line and state: Everything below this line is for billing purposes only.

Disclosures:

Royalties from UptoDate.com for Perioperative Medicine in the Cancer patient chapter

I appluade the authors for adressing this important aspect of patient care and creating an exaple of a note that represents better communication. May I please suggest a few points as below that can be added to capture the patient status better 1) Daily activity: It helps a great deal to understand if they are able to and motivated to stay active so that interevntion can be planned  if needed 2)Medications: In  addition to the list of medications, what helps is if patients affords those meds? Are they really using those daily? What is the co-pay? Does the patient  need assistance to buy medications?

A teacher of Internal Medicine and Medical Oncology for forty years, I have been alarmed at the loss of narrative in the medical record.  More to the point, copy and paste have threatened to destroy what underlies the narrative: critical thinking.  A recent role I have assumed as an unpaid Professor is tutoring those medical residents thought at highest risk of failing the internal medicine board exam. Perhaps my sample is skewed but I have observed an appalling lack of critical thinking when approaching clinical problems.  So what came first: the loss of teaching of critical thinking or the copy-and-paste electronic health record?   Will the restoration of the "story" solve the underlying problem?  Time will tell. 

Another "blame the victim" EMR article

Clinical MDs have had very little input into EMR design. Most MD's have had EMRs foisted upon them without any say in the matter.

The result are EMR designs tailored not just to billing, but in a "database" format that is familiar to software programmers, not MDs.

With endless data fields that need to be filled individually, even dictation can be difficult. Add to that data that is not pulled into a note, but has to be manually obtained and reviewed, and "fatigue" is inevitable. Most doctors quickly develop the "just get it over with" attitude for good reason.

Untlil EMRs are altered to cater to MDs, the goals noted in the article will never happen.

I don't think I've read a better article in a long time.  Improvement in clinical documentation has the power to really change healthcare delivery for the better.  As a clinically retired internist / hospitalist I now do a lot of expert witness work.  I can say without a shadow of doubt that my 40 plus years of knowledge and experience are of little value when trying to wade through a 1500 page hospital record for a three day admission.  Figuring out what happened to the patient and why is like searching for a needle in the haystack.  The only thing I would add to this excellenct article is a recommendation that nursing notes and those of other clinical providers be scrutinized similarly so that they add to the story recorded in the medical record and don't simply add to the verbiage / data dump.