{"id":439,"date":"2009-06-16T08:15:33","date_gmt":"2009-06-16T13:15:33","guid":{"rendered":"http:\/\/blogs.nejm.org\/?p=439"},"modified":"2015-06-04T15:30:37","modified_gmt":"2015-06-04T19:30:37","slug":"q-what-is-the-purpose-of-a-note-in-the-patient-chart","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/q-what-is-the-purpose-of-a-note-in-the-patient-chart\/2009\/06\/16\/","title":{"rendered":"Q: What is the Purpose of a Note in the Patient Chart?"},"content":{"rendered":"

\"\"<\/a>A:\u00a0 Depends who you’re asking.<\/p>\n

The best guidance I ever received on how to write a good note came from my residency program director<\/a>, 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.<\/p>\n

Instead, he urged us to write, as concisely as possible, notes that included the following:<\/p>\n

    \n
  1. What is going on with the patient<\/li>\n
  2. Why we think so<\/li>\n
  3. What we’re going to do about it<\/li>\n<\/ol>\n

    All this gets thrown on its head, however, when you get an email like this one:<\/p>\n

    Hello Dr. Sax,
    \nJust 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.
    \nJudy<\/p><\/blockquote>\n

    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.\u00a0 Oh, and the sentence:\u00a0 “Time spent reviewing impression and plan with patient and family:\u00a0 — minutes.”<\/p>\n

    Yes, abuses by MDs and hospitals on billing have been well documented.\u00a0 Cases like this one<\/a> are obviously serious, and cannot be condoned.\u00a0 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.<\/p>\n

    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?”\u00a0 c’mon!<\/em>) — is anything other than an invitation to game the system with fancy software<\/a>, macros, templates, lots of copy-and-paste, and other such tricks?<\/p>\n

    And what happened to what should be the primary purpose <\/em>of the note — which is to communicate the critical items of the medical encounter?<\/p>\n

    That’s the saddest part — it’s gone.<\/p>\n","protected":false},"excerpt":{"rendered":"

    A:\u00a0 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. […]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3,6,8,9],"tags":[92,93,220,233,286,324,342,561,591,601,799,800,807,860,862],"class_list":["post-439","post","type-post","status-publish","format-standard","hentry","category-health-care","category-medical-education","category-patient-care","category-policy","tag-audit","tag-audit-results","tag-communication","tag-copy-and-paste","tag-dr-sax","tag-encounter","tag-explicit-guidelines","tag-level-3","tag-mds","tag-medical-student","tag-residency","tag-residency-program-director","tag-review","tag-social-history","tag-software"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/439","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/comments?post=439"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/439\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=439"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=439"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=439"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}