Ridiculous Study of the Week: Shorter Notes

The smart people have figured out the way to fix burnout and the answer is:

Writing shorter case notes is one of the key strategies to address EHR-related physician burnout, the researchers say.

Well, there you go.

“The hours spent cloning notes in a mandated doctor-computer relationship leaves the physician unable to experience the best part of being a doctor. No humanistic physician gets up with zeal in the morning, hopeful for a chance to have a meaningful relationship with Epic or MEDITECH. Rational people should feel cynical if the institutional accomplishment for the day is to produce 20 cloned medical records,” the researchers wrote.

This is 100% true but the bottom line is that the system is built around meeting the insurance/Medicare criteria and metrics that these same researchers set up!!  Instead of going back to the SOAP note, which worked so well for years, they recommend these easy steps:

  1. The physician should record the patient’s presenting complaint and all pertinent data that helps the doctor formulate the differential diagnosis (DDx) and a plan for concluding the visit.
  2. Pertinent data can include testing, consultation, procedures, or medications.
  3. Further documentation can degrade the quality of care because the doctor must attend to the computer keyboard and occupy the record with templated data that confound and camouflage the key patient care issues the next time a doctor sees the chart or the patient.
  4. Take notes as the questions are being asked and look at the patient while inputting information into the EHR.
  5. Use a basic template that auto-populates medications, vital signs, and simple exams.
  6. Have separate templates for children and gynecological exams.
  7. When formulating assessments or diagnoses, omit templates and hand-enter problems or assessments with alternative diagnoses. Physicians should include why preferred and alternative diagnoses are possible, which will help explain diagnosis reasoning in future viewings of the record.

Boy, that sure sounds much shorter to me.

Get one of our books here