“My medical assistant populates the past medical, family and social history in every note.”
Reading hundreds of medical records each month, I’ve come to the conclusion that less is more in physician documentation. I’m singing a different song this year, from the one I and many other documentation specialists sang in previous years, when we implored physicians to add detail to their notes, describe their clinical thinking more fully and in general, produce more words. But, that was before Electronic Medical Records.
Using an EMR to document an office visit or hospital admission produces pages of information that no one reads or wants. I know: EMR notes aren’t meant to be printed and sent, but the dirty secret is that since medical practices don’t all use the same EMR, many notes are printed or faxed to another physician. And, looking at the visit documentation within the EMR is often the same as looking at a long, flat document. Filled with information that no one else wants or reads. And, yet, physicians complain that the notes they receive from other physicians hide critical information.
Over the coming months, I’ll write in more detail about what I think would improve the quality of EMR notes. When I audit records, this is my gold standard: can I tell why the patient was seen that day, what happened during the visit and what the medical provider recommended. Or, in other words, could a covering provider use the note to treat the patient?
I often question, do we really need the medical assistant to load family and social history for every follow up visit? How often is the treating physician really reviewing that information with the patient? Is it relevant to today’s visit? If the answers to those questions is it’s not needed, it’s not reviewed and it’s not relevant: leave it out. Less is more.