An ongoing dialogue on HIV/AIDS, infectious diseases,
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:
- 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.
Paul E. Sax, MD
Associate Editor
NEJM Clinician
Biography | Disclosures & Summaries
Learn more about HIV and ID Observations.
FROM NEJM — Recent Infectious Disease Articles- Subacute Sclerosing Panencephalitis after Measles Infection February 21, 2026A 7-year-old boy was brought to a hospital with a 3-month history of cognitive deterioration and seizures. He had contracted measles at 7 months of age while living in an area where the infection is endemic.
- AI-Enabled Precision-Education Systems — Transforming Lifelong Learning in Medicine February 21, 2026Trainees’ paths to safe, independent practice are variable. Artificial intelligence could help accelerate implementation of competency-based medical education to support individualized development.
- Revival of Ethionamide by Alpibectir February 19, 2026Ethionamide has been used to treat tuberculosis for decades, but dose-dependent toxic effects have limited its use. In this trial, alpibectir enabled the ethionamide dose to be reduced by two thirds.
- Peritoneal Coccidioidomycosis February 19, 2026A 23-year-old man presented with a 2-month history of unintentional weight loss and worsening abdominal pain and distention. He had recently moved to Arizona from a remote Pacific island.
- Reducing Tobacco Use Worldwide: Tobacco Cessation among Nondaily and Low-Intensity Smokers — Challenges and Opportunities in Latin America February 19, 2026In Latin America, though overall smoking rates have declined, nondaily and low-intensity smoking are increasingly common, and tobacco-cessation resources remain underdeveloped in many countries.
- Subacute Sclerosing Panencephalitis after Measles Infection February 21, 2026