Home Forums Discussions General Discussion Documentation for physicians and lawyers

So, recently, I am going through a rather unpleasant experience which is still ongoing part of which is why I have been off the board for a while. Of course, I cannot go into that as it is ongoing, but one thing that has come from it is better documentation.

I have several questions, and it will get confusing since answers and follow-up questions will be intermingled with each. But, I don't think starting four threads makes sense.

So, below:

First, while I have championed this in the past, I feel like templates are probably the fastest way to chart but the worst for documentation. Drill down EMRs and those that make you fill in windows take a long time and created six-page notes (think Centricity), but they generally force one document well. While this covers all the bases, I still find dictation the most accurate as it truly captures what the provider heard, saw, thought and did, etc.

I find with templates, it is all too easy to pick one that does cover the finding (left ear redness, etc.), but the auto-population on some choices lists that the cardiac exam is RRR with nl S1 and S2 and no murmurs, rubs or gallops even though later you end up referring them to cardiology. Plus, it is all too evident that you are using templates as the wording never changes.

My CMA uses a template on wcc and it constantly says, pt presents for wcc with mom and has no complaints. Although, he really came with his mom and dad and has questions about sore throat.

So, I have decided to move toward dictation with DNS (this will be an entirely different thread for recommendations so to save a lot of time other than telling me that DNS is the way to go or that dictation is the worst way to go, we can save that part.

A lot of this is based on E & M coding with the number of bullets necessary for each. One question I have is on VSS. Obviously, VSS would be and should be based on each visit. Someone with cough and fever should have HT, RR, Temp, and O2 sat at the least plus/minus O2 sats. I read somewhere once, and I may be mistaken that VSS should include at least three. But, I see why weight is always important but height may not figure into ear pain. Does anyone think that there should always be a default such as Ht, temp and B/P (or pulse)?

Finally, at least for now, and I have other questions on workflow documentation as well. As I have recently learned, no matter what you document, there are certain people out there that can spin the hell out of anything.

But, here I have questions on ROS. Again, template ROS with 10 words there to that default to no, and then are changed to know, again show that templating was used and too often the patient has severe pneumonia and Resp reveals normal.

But, I have seen a trend that is going on especially in the ED, where after a fairly detailed HPI, the ROS will say a 10-point ROS was taken and was all negative except for those mentioned in the HPI.

And, some will have GI documented as Denies and then lists ten things such as denies nausea, vomiting, blood in stools, abdominal pain, constipation, diarrhea, etc. Then c/o vomiting is changed and is in bold. This makes it appear as though all of the things in the GI ROS was asked but when there are ten or twelve of these that are detailed like this, there is no way the provider went through all those. It just seems like, once again, a "detailed" template was used where maybe diarrhea was the actual chief complaint. Thoughts here would be helpful.

I just want to comment (and this is in no way a good or bad thing about specialists), but I recall when I did H & Ps in residency or as an attending or ER notes, I spent a good deal of time going through the ROS. A consultant has a little more time and is also expected to provide a thorough and accurate note and so does not have a template that lists six abbreviations with Cough, Fever, Diarrhea, etc. But, it would be hard to go through a thorough list with OM.

For me, my homework is to work on better HPIs, definitely better exams which are either typed or dictated and, therefore, accurate, and more time on decision making and rationale. I think that is somewhat missing on the assessment and plan approach. Not that it can't be done, but with our ED it is obvious this was an issue given every ED note now contains a decision making and rationale section where they actually overdo it with a pt with fever making them think of encephalitis and meningitis along with viral syndrome, most of the time with appropriate reasons why they are not. Of course, if you mention meningitis, does the attorney then ask why you didn't do an LP?

Again, it is difficult for the busy PCP to have a patient with left ear pain and an exam that is c/w a bulging red ear on the left to choose Acute Left Otitis Media and then prescribe amoxicillin. But, eventually that approach catches up to you. Of course, there is my still biggest pet peeve of the CC being listed in Past Encounters. I haven't figured out how four diagnoses can be listed for one past encounter, but when the patient's chief complaint is fever X 4 days and not feeling well, that just looks horrible in the past encounters especially when a parent asks for how many ear infections their child has had.

Physical is perhaps the easiest part for me. I try to be consistent all the time. So even though it is an earache, I listen to the lungs, heart and abdomen and check the abdomen. I note how they walk in and out and of course all the ENT things. So a template as a base works, with modifications as needed.

I have a large number of templates that are regional if I am only doing a knee or ankle exam but that is a small percentage.
H&P can be challenging. I do a lot of typing and I am fairly good at it. Some can be templated in, with the appropriate responses. I would agree that DNS is probably a better solution but often is slower than typing. (I have not used DNS in a long time, and I am sure it has made strides.)

ROS can be templated, you just have to change NO to + appropriately and delete those that were not asked. Some of these can be done by MAs as they get your initial information.

But what works for one may not work for all.

Thanks. Yeah, it's funny how quickly I could dictate an H & P, especially the exam in my hospital days. But, I am going through something now, I have never gone through before. It is extremely difficult. And, documentation was an issue.

I used to do ROS with my nurse doing them. And, my nurse would do a good portion of the HPI. I guess it is similar to an ED note where there is a nursing triage note. But, the problem is there just has to be one word like RUQ pain in a three line nursing note that is not talked about in the room, and that is pounced all over. And, there is really nothing you can do. "Didn't you see this? What would you do normally had you known that?" You lose either way. You say, I do this or that. "Then, why didn't you do that?" Or I didn't read it. "And, it's why not? What it is there for?

I know what you mean by the template and editing things. But, you get in a hurry. Sure, you listen to the heart on the ear infection. And, maybe you hear a click or a murmur. And, then you order a cardiology consult. But, they don't correlate. Or you generally do what the template says you do, because you always do it. But, you didn't this time. So, now nothing is believable.

I definitely understand how you do it. That is how I did it. I certainly am not doing it that way anymore. David used to talk about this all the time. I don't know how many times I have left cough NO, and then diagnosed a pneumonia. It also depends what you call a good review of systems. Again, big difference between an admission H & P, a consult note, and a progress note. But, a ROS that states, "Denies nausea, vomiting, abdominal pain, diarrhea or bloody stools," is different than GI: NO.

I will say it takes longer to do than a template. But, if I type exactly what I did in the physical exam, it is correct. Even if I leave out abdominal exam when I did it, I am likely not going to type RRR, nl S1 and S2 with no murmurs, gallops or rubs (probably not that detailed) if it was abnormal.

The other thing that gets me in trouble is the following: You see a patient for an ingrown toenail. You deal with it. You sing off. Then the patient brings up a question of a referral. You agree. (Sure, I probably should have brought them back or done an addendum), but now there is an ENT referral with no documentation as to why. And, no matter how many times you tell your referral person not to send that note, they do 15% of the time.

Not arguing with you. Just getting advice. Or seeing how others do it. But, my nurse types in the chief complaint with just basic words, and changes the social history and reconciles the meds. I don't know how many times it says lives in Brewer with mom and dad, and now the patient lives in Hermon with just mom.

Again, the problem can be the mom states ten things to the nurse (which should be read) and then tells you the patient has constipation.

Bert,
I just read most of this and I can probably imagine as a former PM what started this entire line of questions and answers here. I'm so sorry to hear that you are going through this garbage my friend.

Before I read this I already had shot you a PM about something else. Hang in there and keep the faith.

Paul

In my office the nurse does the c/c and HPI and I do everything else. I use a template I made for my standard ROS and I do my best to actually go through it with each patient. Most of my regular patients thinks it is funny but lets face it, it is fraud and abuse to bill medicare for an intermediate visit without doing it. I do remember one patient had no respiratory complaints, just felt sick, but had physical finding and a positive CXR for pneumonia, so it can happen. I also have a template for my standard complete physical and one for what I call a short physical. If what I actually do strays too far from one of those I type it in from scratch.

I got a letter from Humana a couple of days ago expecting everyone under 20 should have a growth chart. All the payers expect a full set of vital signs so I expect my nurse to do one on every patient.

BTW, dictation isn't perfect. Did you catch this the other day? "Transcription software is tied to substantial error rate" http://univadis.com/player/yihzkepe...hebgu&ts=2018071600&o=tile_01_id

I routinely get 10 plus page records from the big local hospital network where the patient tells me the doctor didn't spend 60 seconds with them or lay a finger on them. It is obvious that their system is geared for reimbursement.

I apologize for not getting back on this question. The reality is it has been difficult to read and assimilate the overwhelming response. Maybe after a weekend of having a chance to look through them any posts, I will try to respond. Meanwhile, I apologize.