Reimagining physician documentation

Craig-Joseph-1Physicians write notes. We write notes in the clinic. We write them in the hospital. Sometimes we don’t write them at all, actually. Some doctors dictate their notes so that a human (or more commonly now a computer) can type them up and put the notes where they belong. No matter where or how we write notes, documenting interactions we have with patients is essential for healthcare to function.

Physicians write notes for many reasons:

  • To remind us what we found, said, and did
  • To communicate to other clinicians what we found, said, and did (aka continuity of care with our colleagues)
  • To help defend us against a malpractice accusation
  • To prove that we practiced quality care
  • To engage patients in their care (see also “shared medical decision making”)
  • To allow us to get paid for services rendered

As I wrote about last month, new ways of determining the proper charge for clinic visits will go into effect on Jan. 1, 2021. We’ll eliminate relatively onerous and prescribed guidelines (e.g., how many bullet points for your physical exam did you include) and replace these with either time-based rules or recommendations based on aspects of medical decision making. Under any circumstances, according to the American Medical Association, the goal of the updated evaluation and management (E/M) codes is physician burden reduction: Doctors should not feel pressured to put information in their ambulatory notes that isn’t necessary for patient care.

Now is the time to reimagine how physicians document outpatient (or office-based) care. It’s been 25 years since we last had this opportunity, so I say go big or go home. Given that most doctors use an EHR, we are obligated to think not just about what information belongs in an ambulatory note, but how that information gets into the note.

Note bloat has many causes, but chief among them has been the perceived requirement to meet regulatory needs. Now is the time to create or update documentation etiquette guides (see this excellent example from Weill Cornell, NY Presbyterian, and Columbia) to ensure that all physicians are on the same page with respect to basic requirements. For example, will doctors write SOAP notes or APSO notes? Should clinicians routinely include vital signs in their notes if those data are already included in the encounter summary report? A little bit of standardization and agreement can go a long way.

I’m a believer that documentation templates are great when they make sense and horrible in all other circumstances. As you reimagine physician clinic notes, examine the most commonly used templates and ensure that they are not overly broad or generic. The best templates are typically focused on a specialty or used under certain conditions such as a commonly performed procedure. Remember that a template need not be a complete note; often the best templates are like Lego blocks that can be dropped into a note only when needed.

EHRs have been blamed in part for making it easy to add potentially extraneous information into a clinic note. Copy and paste is one source of the problem to be sure. Another issue is functionality to incorporate large amounts of discrete patient data from the chart into the note (e.g., Epic’s SmartLinks or Cerner’s Dynamic Documentation). It rarely makes sense to include an imaging report or a complete list of lab results in a progress note. As physicians reconsider their notes, those responsible for EHR configuration should think twice about functionality that makes it easy to bring in lots of data.

Clinicians need to consider that more patients will be reading their notes. Thanks to the work of the OpenNotes movement, physicians are increasingly engaging their patients and directly involving them in their care. New rules from the federal government regarding information blocking will inevitably make clinic notes ever more available via the patient portal or other applications. Should physicians significantly revamp the words they use given that their patients will likely be reading them? Yes and no. I think CT Lin, MD (CMIO at the University of Colorado) has the best specific set of recommendations for the thoughtful physician to contemplate.

We physicians should take full advantage of the opportunity to reimagine our clinic documentation. It’s been several decades since coding guidelines have significantly changed. Let’s not wait several more decades to act.

Learn more about how to prepare your organization for E/M coding updates by attending our upcoming webinar, E/M Code Changes: What will happen to the physician note?


Topics: Advisory, featured, Performance Improvement

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