June 16th, 2009

Q: What is the Purpose of a Note in the Patient Chart?

A:  Depends who you’re asking.

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:

  1. What is going on with the patient
  2. Why we think so
  3. 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.

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.

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HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

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