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    Friday, July 02, 2004

    Evolution of a Note: I've got documentation fatigue. Having not yet brought my office completely into the electronic age, the endless grind of writing down everything that passes between me and my patients day after day is getting to me. What was once brief enough to be called a "note" has evolved into a short story.

    Once, doctors' notes were just that - brief notes to jog the doctor's memory. I have a patient whose previous doctor died at the age of 90. When she transferred to me after his death, his office notes transferred to me, too. She's a young woman in her twenties and had been his patient since her infancy. His medical record from those twenty-some years fits entirely on a 3x5 card. He didn't have chart racks, he had card file boxes. A typical entry looks like this: "7/1/88- ROM -Amox." That's it. The thing is, I know what that means. And so would every other primary care physician. She was treated for an infection in her right ear with amoxicillin.

    Contrast that with the "properly done" modern note:

    Subjective: Eight year old white female complaining of right earache for three days. No fever. Preceded by one week of runny nose, cough. No headache, no shortness of breath, no sore throat. No change in her past, family, or social history. (If she's a new patient that would have to be fleshed out. It would need to include who she lives with and their smoking habits, whether or not she's ever been hospitalized or had surgery, and if so why, and the medcial history of her immediate family members.)

    Physical Exam: Temp- 99.9 Pulse - 98 BP 100/60 Respirations 18

    Alert, pleasant, no acute distress
    HEENT: R TM red, bulging. L TM normal. Nasal mucosa edematous and boggy. Pharynx benign. Conjunctiva without injection.
    NECK: Supple. Shotty right anterior cervical nodes. No masses. No thyromegaly. No nodules.
    LUNGS: Clear, with good air movement bilaterally.

    Assessment: 1. ROM

    Plan: Amoxicillin 250 mg po TID x 10 days. Disp: 30 Refill x zero.
    Discussed expected course of illness, mother to call if deviates.
    Discussed possible side effects of medication.

    Even using all of those abbreviations, it still took me about five minutes to type that. And that's a brief and easy note. A note for a diabetic with hypertension and heart disease can easily run two pages. And yet, if I died tomorrow and my note passed on to the patient's next doctor, he wouldn't get any more useful information out of it than "ROM - Amox."

    Why did the note change so much? Well, the obvious answer is that it changed for legal defense reasons. The most oft-repeated phrase I heard in my clinical rotations in medical school was "if it isn't written down, it didn't happen." Some time in the 1970's the doctor's note stopped being a document intended for himself and other doctors and became one intended for attorneys and juries. That's when the note expanded to its modern form. But it's taken another step forward in the past ten years. It's now also a document for third party payers who review the doctor's work. And the problem with that is, they neither like nor understand the abbreviations, which makes it an even longer writing process.

    Our hospital pays people to go through all the patient charts (while they're still in the hospital), looking for documentation glitches that may be used as excuses by third party payers to shirk their duty. They leave post-it notes on the chart with suggestions for better documentation. Sometimes it's a reminder to include a minor diagnosis in the progress note. (Like a headache for which the patient was given Tylenol the night before.) But, sometimes, it's a note requesting that physician short-hand not be used. For example, hypernatremia, which means a high sodium, is often expressed in doctors' notes as upward pointing arrow next to the chemical symbol for sodium, "Na". But, according to the reviewer, "upward arrow Na" is not a Medicare-recognized diagnosis. Of course it is. It's shorthand for hypernatremia. And a commonly used, unambiguous shorthand, too. But, we have to march to the tune of he who pays, so my notes just get longer and longer.

    Someday soon, I'll buy an electronic medical record, if my malpractice insurance premium allows it. I hope my hands can last.

    posted by Sydney on 7/02/2004 07:39:00 AM 0 comments


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