麻豆传媒

In the evolving world of healthcare, what should the medical record -- and in particular, the 21st century progress note -- actually look like?

Our notes have changed and adapted over the years, especially as we went from paper charts to the electronic health record.

The Perfect Pen

Many of us still remember those hours spent over paper charts, writing out in longhand the chief complaints, HPIs, past medical history, past surgical history, medications, family and social histories, allergies, review of systems, physical examination, assessment, and plan. Hours sitting in the nurses' station or the residents' work room late at night, finishing up our admission notes and progress notes from the day, making sure everything was ready for rounds the next morning.

Built into this was the search for the perfect pen, one that wrote smoothly with the perfect paper feel, didn't smear (especially important for us left-handed folks), nice enough to be worth holding onto but not so nice that someone would steal it if you put it down for a minute, and certainly nothing branded by a drug company (although they sometimes had the coolest ballpoint pens!).

When we switched over from paper charts to typing in the electronic health record, things got easier, especially for those who knew how to type really well (not me; I still hunt and peck). Then, more and more tools became built into the system to allow notes to be fleshed out with a few clicks, smart sets, macros, and copy-forward that filled things out -- histories, physical exams, and review of systems that were often partial works of fiction.

Our notes have evolved over our professional careers as well, as we've grown from being medical students to interns to residents to fellows to attendings, learning and adapting what we need to document, and what makes for a good progress note. The ballooning of so much of this documentation has unfortunately been less about the actual clinical history and more about billing and compliance, which has over the years probably caused more harm to those who write these notes and those who try to read them than many other "innovations" in healthcare.

Changing Requirements

In recent years, the requirements for documentation have changed, and these days less is required to document complexity of care than just a few years ago. It used to be that the auditors would go through your HPI with a fine-tooth comb and tick through a checklist of all the things that needed to be included to reach a certain level of medical complexity: how many review of systems you documented positives and negatives for (or at least asked about); how many organ systems you examined (or at least said you did).

Now we have begun to move towards just needing to document medical complexity, and although old habits die hard, my hope is that we can move even more towards creating an electronic health record documentation of our interactions with our patients that truly reflects what went on in the room, what a patient told us, what we found when we examined them, what we were thinking, and what we plan to do about it.

In an article in the , investigative reporters looking into fraud and abuse at methadone clinics talked about how charts would document counseling sessions for patients who were receiving their methadone dosing at certain clinics, while whistleblowers were revealing that counseling was often a brief check-in while the patient was waiting in line for their day's dose rather than an actual 40-minute sit-down conversation offering wonderful supportive advice that these patients probably desperately needed and deserved.

The company involved clearly stated that this was not true, that they never told people to document things that didn't happen, and that all of the people who worked for them provided all of the care that they documented in the chart. (Interestingly, at one point in the article, the company spokesperson says they do not condone workplace retaliation, although I'm not sure there's any company anywhere that would say that they condone anything like workforce retaliation as part of their worker's handbook of acceptable behavior.)

We've all read through notes that clearly look bloated -- endless detail that we didn't think was really going on in the room between a doctor and the patient. Sure, there's a lot we can surmise about what is and isn't going on with our patients based on how things go through the course of our interview and exam, without explicitly asking. That has a great deal to do with our clinical "spider-sense," our medical radar, our intuition into what's going on with our patients. Long, detailed progress notes that contain month after month of visits piled up on top of each other really serve no purpose, and this compendium of documentation should be stored elsewhere.

The Promise of Improved Technology

Hopefully some of the newer technology that people are working on can help us get to a more truthful, effective, and efficient communication of what went on in the room between us, creating a clinical truth that helps move healthcare forward. We've all seen notes that have detailed histories and reviews of systems and physical exams that just don't make sense, in which we all pretty much get the idea that it didn't actually happen.

I'm not saying that anyone's doing fraud here, and rarely have we heard of situations where patients who have read these notes on the portal say, "This isn't accurate; someone's trying to get away with something." But I'm hopeful that some of the new artificial intelligence and ambient listening/voice recognition systems may be able to help us generate this clinical truth for us in a way that saves us all time and energy, and provides plenty of documentation to keep the billing and coding folks happy.

Those programs I've tested and those I've seen demoed seem to mostly mangle what goes on between a doctor and a patient, spewing out stuff that does not sound like how we think, speak, or write. Perhaps someday, as data storage gets more efficient, we might be able to simply videotape the entire clinical interaction, and have this stand as the medical record of what went on.

Maybe this is too fraught with opportunities for stuff to be misinterpreted, maybe in some ways we want to continue to document in the ways we always have. But I hope that we can take these occasions of change to think about building a better system, about being smarter with technology, about helping us be more efficient at getting through the work of documenting to the real task of taking care of our patients.

Take me at my word.

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