A patient’s chart should reflect their visit. In fact, it should be a story. Just as a book or a movie, there is a beginning, a middle and an end. The beginning is their complaint and the story behind it. The middle is your exam and possible work-up. The end is your assessment and plan. Now that is out of the way, here is my point. In that assessment and plan there should be….a f%cking assessment and plan! That is why they call it that. I can’t tell you how many times I see the diagnosis in patients’ charts with nothing else. Nothing. It will just say “Headache” and maybe a lab. That is all. Unbelievable. Other times I may get lucky and see a cryptic note with something like “bw done. F/u if no better”. I have seen that last one many times. Why? Because I wrote it! And I hate myself for it!
Why is it like this? With the advent of the electronic medical record came shortcuts. These shortcuts have ruined the chart. Most of the crap in there is useless or plagiarized. The filler is the biggest part because that is what enables the doctor to upcode and optimize his or her billing. The problem is that no one really reads this garbage. The reader or moviegoer wants to know the beginning of the story and then see how it ended. Most EMR records (trust me, I have become more and more guilty of this too) have no narrative. There is NO story. In the old days I would dictate and then give a whole paragraph on my thoughts. I would give my opinion of what I thought was going on and why. Do you see that today? Rarely. I would outline what I was going to do and why. I would give a differential diagnosis. I would detail what I told the patient and why. This is not happening anymore, it bores the reader, and it is bad for medicine.
My former medical partner said that when he saw an old dictated assessment and plan of his recently a tear actually came to his eye. I would say this about ALL of medicine but I get his point. Unfortunately, I don’t see this changing. The new guard is comprised of “click-happy” kids who have lost this art (or never had it). They are treating numbers and not patients and all they worry about (because that is what the insurers worry about) is getting the clicks done. Their notes suck!
My recommendation is to take the time to at least give a story in the “HPI” and the “A/P”. Think about someone reading your visit and wanting to know what you were thinking. It is so important. Your job is to give your thoughts and help the patent and not make insurance companies happy. If you are practicing Direct Primary Care, however, then you know what I mean because you have the time to document in a meaningful way because your only employer is the patient.