An ongoing dialogue on HIV/AIDS, infectious diseases,
June 16th, 2009
Q: What is the Purpose of a Note in the Patient Chart?
The best guidance I ever received on how to write a good note came from my residency program director, who told us that a note needn’t be encyclopedic to be excellent; in fact, he urged us to get away from the “second-year medical student” style, which typically includes absolutely everything.
Instead, he urged us to write, as concisely as possible, notes that included the following:
- What is going on with the patient
- Why we think so
- What we’re going to do about it
All this gets thrown on its head, however, when you get an email like this one:
Hello Dr. Sax,
Just a reminder that I will be meeting with you to discuss your billing audit results on Thursday 5:30 pm, right after your outpatient session is completed.
Judy
In this meeting, I predict Judy will tell me that the occasional visit I coded as “Level 5” really should have been “Level 4”, or even “Level 3” — since even though the case was incredibly complicated and involved reviewing years of treatment history, lab results, and prolonged communication with outside providers and the patient and his family members, I somehow neglected to include the requisite # of “Review of Systems” (10 required), with explicit mention of past, family, and social history, as well as a 9-system physical exam. Oh, and the sentence: “Time spent reviewing impression and plan with patient and family: — minutes.”
Yes, abuses by MDs and hospitals on billing have been well documented. Cases like this one are obviously serious, and cannot be condoned. It could be argued that these periodic “compliance reviews” (my session this week with Judy) are merely the just rewards of a previously unpoliced system.
But does anyone think that the current rules we have in place — with these explicit guidelines for what constitutes a complex case based on who knows what (“Review of Systems?” c’mon!) — is anything other than an invitation to game the system with fancy software, macros, templates, lots of copy-and-paste, and other such tricks?
And what happened to what should be the primary purpose of the note — which is to communicate the critical items of the medical encounter?
That’s the saddest part — it’s gone.
Categories: Health Care, Medical Education, Patient Care, Policy
Tags: audit, audit results, communication, copy and paste, dr sax, encounter, explicit guidelines, level 3, MDs, medical student, residency, residency program director, review, social history, software
You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed.
Comments are closed.
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
Biography | Disclosures | Summaries
Learn more about HIV and ID Observations.
Follow HIV and ID Observations Posts via Email
- Brave New Name — How PCP Became PJP and Why It Matters
- The Riveting Conclusion of How PCP Became PJP
- Musings About a Bruising and an ID Link-o-Rama
- Marking a Social Media Mass Migration — Until the Next One
- Why We Have Antibiotic Shortages and Price Hikes — And What One Very Enterprising Doctor Did in Response
- ID Cartoon Caption Contest (125)
- ID Cartoon Caption Contest #2 Winner — and a New Contest for the Holidays (92)
- Dear Nation — A Series of Apologies on COVID-19 (80)
- How to Induce Rage in a Doctor (77)
- IDSA’s COVID-19 Treatment Guidelines Highlight Difficulty of “Don’t Just Do Something, Stand There” (74)
-
NEJM Journal Watch — Recent Infectious Disease Articles
- Sulopenem Etzadroxil plus Probenecid (Orlynvah) for Uncomplicated Urinary Tract Infections
- Radiolabeled p-Aminobenzoic Acid as a Marker to Detect Bacterial Endocarditis
- Clostridioides difficile Vaccines: Promising Contenders
- Observations from ID and Beyond: Marking a Social Media Mass Migration — Until the Next One
- Incidence of Autoimmune Diseases Involving the Skin, After Acute COVID-19
-
Tag Cloud
- Abacavir AIDS antibiotics antiretroviral therapy ART atazanavir baseball Brush with Greatness CDC C diff COVID-19 CROI darunavir dolutegravir elvitegravir etravirine FDA HCV hepatitis C HIV HIV cure HIV testing ID fellowship ID Learning Unit Infectious Diseases influenza Link-o-Rama lyme disease MRSA PEP Policy PrEP prevention primary care raltegravir Really Rapid Review resistance Retrovirus Conference rilpivirine sofosbuvir TDF/FTC tenofovir Thanksgiving vaccines zoster