I also think it won't stop because of the over reaction to medicolegal insanity. At some point, this gets in the way of good medical care. Yes, it helps your coding and yes every little thing is documented. But, at what price? At the price, that while I many times will glance at the first sentence of the HPI, IF I can find it, I read no more.
The entire note is templated. I don't mean the type of templates, where clicking on left OM, produces a full note that one would think would be produced for that. But, you must fill in every blank. VSS are done three to four times, OK, if done, could help patient care and document that you sent the patient home once the fever was lessening.
But, the medication list being included three or four times, drives me nuts. I can't even figure out what was given added, or deleted. In many cases, I will see where they will call it pharyngitis and write for a medication. Then I have to look everywhere to find the result of the RSA. Or if it were done.
While the reconciliation of the meds seems like a great idea, it doesn't seem to be that beneficial in the ED. If I reconcile all meds, my med list is up to date. But, when they do it, great they leave on their medication list, but if I will admit I don't read through the note, see that they took them off something and add something, and then change their med list in AC. I do reconcile if they f/u. I actually try to reconcile at every visit.
We have have one hospital which includes all the labs in the middle. Their notes are dictated and more straightforward (I still find a dictated note to be the best), but they include the labs in the middle. The font is so light, you simply CANNOT read them. They take up two to three pages, and I seriously mean you cannot read them. I have called medical records, and they say, "My gosh, you are right." That was four years ago.
