The notes are built to maximize the billing that we do. But frankly, even though I revisit a patient's chart and check their past medical history, update their meds, update their family history, review their social history, etc. IT DOESN'T NEED TO BE REPEATED IN THE NOTE! However, if I don't rewrite all that, Medicare or the insurance company doesn't believe I did it and I can't charge for it. As a consequence everything is repetitive and finding the little gem of information one needs to care for the patient becomes more and more difficult. As anyone who has ever received the reams and reams of paper from an ER with an electronic health record (EHR) that has no discernible font changes or indentation can tell you, it is next to impossible to determine why the patient was there, what treatment they received and what followup they need.
To counteract this I dictate my medical reasoning in the discussion box at the end of the note. Next visit that's where to look to find the important stuff. Of course this increases the amount of time documenting, taking away more precious moments I have to spend with the patient creating inelegant notes that are one step away from being worthless for subsequent treatment.
What if we could create two notes for every patient. One that went in to the billing records for auditing purposes and one culling the important stuff into a true "patient care note". Surely there is software that could help us with that.
To quote Dr. Vartabedian: What do you think?
1. We need to reassess the patient note. http://www.kevinmd.com/blog/2013/08/reassess-patient-note.html
2. The doctor will see your medical record now. http://www.slate.com/blogs/future_tense/2013/08/05/study_reveals_doctors_are_spending_even_less_time_with_patients.html