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.

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Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected]

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12 Responses

  1. Sudha M Prasad says:

    Fellow Learned Doctors:
    How does one do this? I can’t figure it out!
    “Take notes as the questions are being asked and look at the patient while inputting information into the EHR.”

    It could end up looking like this:
    “yslr mpyrd” (“Take notes”-when your hand is over one on the home row of the keyboard…)–our own “Enigma”…

  2. Pat says:

    Friends, colleagues, detractors, and layabouts,

    A couple of other points:

    1) Diff Dx – I have to put it on my charts for proper coding. Firstly, it is an insult, as it should be ASSUMED by virtue of my training that I have formulated one. Secondly, it is a gift to lawyers. Any possibility noted must be thoroughly ruled out; any possibility not note suggests too narrow a scope. Both are blood in the water. Which leads me to …

    2) Lawyers – Our society is awash with greedy and/or vengeful patients and/or family members. Simple notes based on expertise and clinical presentation are near-worthless in a bad outcome. A symple note stating “C/o fever, myalgias x 2days; Dx Flu; Tx: Supportive” is another rat bastard lawyer’s beach house when the disease progresses to viral meningitis and the kid dies 3 days later.

    The now-expected novella chart note is a manifestation of society’s mistrust of doctors, and that won’t get better.

  3. Dave Mittman, PA says:

    Medical records are important and a uniform way of doing them is crucial for everyone to communicate. Long gone are the days of the private office when no one would see anyone’s records. But there has to be a way to do it better and easier. The above does not seem like the way.
    Dave

    • RSW says:

      Disagree.

      Paper charts, a good transcriptionist, and a well-trained staff that obtains the info I need in advance – works every time.

      I almost never lack what I require using this system.

  4. Bill Ameen, MD says:

    Dr. Doug,
    Ha! Totally agree. I actually grudgingly adopted the SOAP note which came about while I was in training. The problem was you had to do a SOAP for EVERY complaint the patient had, all written out in longhand (because that’s was primary care is all about, taking care of the patient from head to toe, and most people are full of complaints). Somehow I don’t think we’ve improved care all that much since GP’s kept their records on index cards in a small file cabinet. “Billy—3/1/57–Strep–Rx penicillin 1 cc. JM”

  5. john parkin says:

    When I wade through this electronocrap, it is so obvious that the doc did not personally do most of this counterproductive activity. PERRLA and DTR on every patient ?? This is fraud ! Who c ares as long as the $$ gods pay. Many notes don’t have a clear conclusion and plan. Useless.

  6. Mario says:

    So far I’ve read that burn out can be anything from a “Moral injury” to, now, poor typing skills. Who knew all it took to combat this phenomenon was shorter notes. Who knew?

  7. Steve O' says:

    Touch-typing while smiling at the patient makes me feel like Liberace. I want to sing “Piano Man” by Billy Joel.

  8. David Fitzpatrick MD says:

    King Doug,
    I hope that you will help me to popularize the term “Click Static”.
    It is the massive amount of useless data 1/2 page visit note and turns it into a 7 page tome (amazingly enough perfectly and completely filled out despite the 8 minutes allowed for the visit). Click Static puts so much noise around the rare nuggets of useful data that it impairs the VERY PURPOSE of the medical record. It also degrades the sacred nature of the information recorded in the medical record. Because we all know that the data is not being asked at each visit (as it is being billed for).

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