HIV and ID Observations

When it comes to writing consult notes, it often seems as if we ID specialists have a blatant form of obsessive-compulsive disorder. Every detail is fair game — travel history, dietary habits, all sorts of seemingly trivial exposures, and of course microbiologic data stretching back to the Cretaceous period.

I’ll never forget receiving sign-out from the graduating first-year ID fellow when I started my fellowship.  It included a photocopy of a consult note she had written the day before on a woman with fever after gallbladder surgery.

In five pages of meticulously-detailed prose, there was this memorable item from the Social History:

Two pets at home:  a dog (Rusty) and cat (Cleo); both are healthy.

Good news for Rusty and Cleo!  But what could this possibly have to do with post-operative fever after gall bladder surgery?  Even if you allow that perhaps she was suffering from some bizarre post-cholecystectomy zoonosis (if there is such a thing), why was it necessary to cite the pets’ names?

Electronic medical records have, if anything, made matters even worse for the detail-obsessed.  The ability to cut and paste endless reams of data into a note is irresistible to most ID docs.

It leads to a bizarre paradox where the more information in the note, often the less useful it is — a phenomenon expertly dissected over here on the always-interesting KevinMD blog.  Says guest writer Jaan Sidorov:

[A doctor] had received a copy of a lengthy consultant-physician’s documentation involving one of his patients and was astonished by the blob of past data, prior notes, test results, excerpts, quotes, interpretations and correspondence that had been replicated word-for-word in the course of “seeing” his patient. The terse portions describing what the patient actually said, what the consulting doctor actually examined and what the diagnosis and plan were were inconspicuously buried toward the end of the EHR document.

And you know what’s most maddening?  Under the current “guidelines” for coding and billing, there are true incentives — both financial and regulatory — to write this kind of text-heavy note, one heavily infused with templates and boilerplate language.  The more complexity the better!

Here’s a proposal:  the goal of a consult note should be concise documentation of what you think, and why, then what you’re recommending, and why.

I’m sure Rusty and Cleo would agree.