Time on EHR/Computer

[Zaphod]

MPMD wrote:

Zaphod wrote:

MPMD wrote:

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I think the best things that can be said about more vs. less documentation from a medicolegal standpoint are the following (I do have some expertise in this area):

1. You really need to document some kind of thought process, very difficult to defend a missed dx that includes no MDM. The deps suck as well especially if there is no independent recollection, just the doc trying to state over and over that they have a standard process they follow. That’s all well and good but if something was actually missed it’s very difficult for your justification to simply be “I always ask my chest pain patients about radiation to the back so I must have done that on that day 8 years ago.”

2. If you find yourself trying to justify not doing something and taking more than one line to do it… you might just want to do that thing. “Despite the sudden onset nature of the intensely pleuritic pain and the red swollen leg I do not think this is a PE because the patient lacks risk factors and their O2 sat is 94% and… oh well dammit I’m just going to order the scan.”

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I unfortunately also have experience in this arena, and totally agree with the second statement, makes no sense order it.

Have not come up against any resistance or struggle in trying to explain thought process as “my standard d/w pts is x, y, z…..” helps to of course have a lot backing documentation where pts were told repeatedly and their signature is there, etc…in my particular case there was consents from office and day of surgery, separate “teaching” care guide and a video they had to watch. Pts issue came up no less than a million times (ok, overstated but it was 9 separate times explicitly mentioned in writing, 3 more times in video).

There is very very rarely just one tiny thing or word that would have made the difference between malpractice and not, and the legal standard is actually incredibly high, its not bad outcomes, its if you were a total dipstick about everything and no other doc in their right mind would have been and that immediately led to the issue.

We were talking about HPI, which I dont find too much use in either as its not the major thing for my specialty as things are acute and focused, but do agree about MDM asess/plan stuff. Thats where the majority of what is written/dictated is for me and my partners.

 

 

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It sounds like you are talking about a procedural complication. I agree that’s probably relatively easy to defend if you’ve clearly discussed it.

It’s also good to realize that while it’s true that you can be sued for anything, your chances of losing are not random. I’ve seem some really craziness where a plaintiff’s case is on its 3rd firm and still struggling to have a certification of merit written by a doc. Read some funny depositions where the defendant doc is pretty clearly struggling not to just say, “um, what was the problem here?” I was once asked if it was malpractice that the patient didn’t have a test performed that was literally a thing. I won’t say the exact term but it would be like asking why you didn’t have a bronchoscopy done on your pt’s rectum? “Um, do you mean a regular bronch?” “ANSWER THE QUESTION DOCTOR!”  I wouldn’t worry about trying to justify that to a med staff office.

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Can be medical after a procedure as well, but a lot of this stuff is varied and particular to each persons field. The main issue is that the public thinks even the doc not giving them enough time or feeling rushed and such is malpractice thus you get slightly more and more paranoid as time goes on. Its a real pain, but good not to let it dramatically change the way you practice for the worse and basically cost you 45 mins a day in needless charting that neither helps with medical care or medicolegal and is basically just a statistical problem.

 

[Zaphod]

MPMD wrote:

Click to expand…

I think the best things that can be said about more vs. less documentation from a medicolegal standpoint are the following (I do have some expertise in this area):

1. You really need to document some kind of thought process, very difficult to defend a missed dx that includes no MDM. The deps suck as well especially if there is no independent recollection, just the doc trying to state over and over that they have a standard process they follow. That’s all well and good but if something was actually missed it’s very difficult for your justification to simply be “I always ask my chest pain patients about radiation to the back so I must have done that on that day 8 years ago.”

2. If you find yourself trying to justify not doing something and taking more than one line to do it… you might just want to do that thing. “Despite the sudden onset nature of the intensely pleuritic pain and the red swollen leg I do not think this is a PE because the patient lacks risk factors and their O2 sat is 94% and… oh well dammit I’m just going to order the scan.”

Click to expand...

I unfortunately also have experience in this arena, and totally agree with the second statement, makes no sense order it.

Have not come up against any resistance or struggle in trying to explain thought process as "my standard d/w pts is x, y, z....." helps to of course have a lot backing documentation where pts were told repeatedly and their signature is there, etc...in my particular case there was consents from office and day of surgery, separate "teaching" care guide and a video they had to watch. Pts issue came up no less than a million times (ok, overstated but it was 9 separate times explicitly mentioned in writing, 3 more times in video).

There is very very rarely just one tiny thing or word that would have made the difference between malpractice and not, and the legal standard is actually incredibly high, its not bad outcomes, its if you were a total dipstick about everything and no other doc in their right mind would have been and that immediately led to the issue.

We were talking about HPI, which I dont find too much use in either as its not the major thing for my specialty as things are acute and focused, but do agree about MDM asess/plan stuff. Thats where the majority of what is written/dictated is for me and my partners.

 

 

[Zaphod]

I have templates for the note structure, but use a mic to dictate directly into the note the pertinent visit specific things. Still have the risks of charting poorly, but think its a good mix, especially since its instant, its also pretty funny what it thinks you say sometimes.

[HandFellow]

Excellent input. I would hate the constant barrage of messages in the emr. Before the emr how was all that infor handled? Stack of papers and a signature?

Agree that over documenting is a thing. On the complicated patients I put a 3 line blurb at the end to summarize. Other than that, mention only the pertinent stuff. But it sounds like the real time suck is the indirect patient care behind the scenes stuff that is a serious drain on resources. How much of that is really necessary ? Can that be done by nurses and extenders? My experienced MA keeps so much stuff from involving me that it probably saves me an hour a day.

[Cubicle]

My fastest notes can be done in 30 seconds.  For a new patient with 3-4 problems ("by the way since I'm here") I can spend 15-20 minutes on the notes.  I hate charting.  My last patient will walk out of the office at 05:30 pm ("Sorry we're late"), but I won't finish the day's charting until 08:00 pm.  I would hire someone to do my notes, but I'm terrified of insurance audits & lawsuits (both happened to close doctor friends of mine, I was privy to all the details) so I'd spend too much time pouring over their notes anyways.  I definitely over-document.

[Allixi]

Whoops, I missed those abbreviations.

Sometimes there is ancillary info in the H&P that will paint a picture of someone’s social situation or long-term issues. This is almost never relevant in the ED, but can be useful for others.

Part of the problem is when people dictate, they ramble on and on and never stop. I have colleagues who write giant wall-o-texts that are a chore to wade through. Paragraph breaks, brevity and direct verbs can go a long way here.

Surely most people are capable of writing, in a concise manner, using conversational English, they just don't seem to have the motivation for it.

[SValleyMD]

I’m convinced that a primary care doc will never understand the emotional angst and toil it takes to cut on someone, to deal with crashing trauma pts or STEMIs, to deal with physician-inflicted complications. It’s nothing that can be seen or taught even with exposure in med school and something they can’t relate to in the least.

On the flip side a surgeon will never grasp what a primary care doc with a large patient panel has to do to manage an enormous EMR load. Not just pre/post clinic visit with a single hand issue, but 20-30 pts daily with 5-15+ chronic conditions, labs, referral notes, insurance denials, etc

Both just completely different worlds.. both can be incredibly difficult..

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For my notes.. I keep a running hx at the top of major procedures, imaging, hospitalizations.. then shorthand the current issues during the visit.. update exam and h and p and 90% of the time sign the note off at end of 10-15 min clinic visit . Work on inbox in between.. Not ideal but world we live in

[Anne]

Zaphod, not to brag, but I think I do it well. Sometimes patients who have had a very complicated course come to me and I think, well I can't fix your problem but at least I can organize your clinical course in an organized, thorough, but concise way and at least that will help everyone else who helps take care of you...if they actually read my note...which they probably don't.

[LIFO]

Typing while talking is a huge contributor to note bloat.  I firmly believe you cannot consistently write a concise HPI while you're listening to the story.

[StarTrekDoc]

overcharting as well as EMR /Insurance related note bloat is definitely a correctable issue.  That's not where the majority of the noise comes from though--at least not in Primary Care.

[Zaphod]

Anne wrote:

MPMD’s comments might apply in the ER but the Chart 1 style of documention wouldn’t work in my area–if you are in an area where continuity of care matters, thorough documentation helps with that. Although I agree, chart 2 is pretty crappy–while it has a few salient pieces of info the word efficiency is terrible.

I see a lot of patients with complex chronic conditions who have had numerous treatment trials with variable success. If their treatment course isn’t well documented a lot of time can be wasted considering the same things over again.

Also, there is interesting research in predictive factors for what acute pain will turn into chronic pain. A review of those risk factors at the time of intitial fracture treatment could help identify who needs closer f/u, etc. and might prevent that patient from being in my clinic 5 years later with chronic intractable wrist pain

That being said, there is a way to be efficiently detailed. I see a lot of resident notes that take 3-4x the words/space that I would use to convey the same info. That makes f/u more difficult, as you are scanning a book of fluff trying to find the salient points.

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Exactly. I think the point is to convey necessary information, sometimes its a good amount. I think that was a bit of a caricature though.

In very chronic type pts I think its even more important to be concise, and make sure you're highlighting the important points and essentially making a bullet point log of events that can be read easily. Hardly ever see it done well. Reminds me of discharging those pts that spent months in the hospital getting multitudes of procedures and surgeries. Good practice.

Its definitely hard in EMRs that its difficult for problems/diagnoses/etc...to be removed and theres no incentive to mess with things, etc...and stuff sort of propagates over time after resolution, etc...

[Zaphod]

nephron wrote:

The 3rd one, medico-legal one, is the one most benefited by additional charting. I’ve been through one lawsuit, I consider it a frivolous lawsuit, but by the time that went to trial, it was ~5 years after the incident and all anyone had to go on was what was written down.

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Disagree strongly. I dont think anyone is saying write a bare minimum. We are simply saying write was is necessary in an efficient manner. The more you write down, the more opposing counsel has a chance to pick you apart and make you take a side, etc....its a double edged sword. I'd lean more than less, but its still true. If its unnecessary, you shouldnt say it, if you hedge too much, counsel will say you saw it coming and knew it was bad and said that to cover yourself, etc...etc...there is nothing perfect.

You just read the chart back and dont act like you remember anything, all extraneous stuff is just leeway to get yourself in a pickle. There are obvious situations which are more likely trouble, and obvious pts and care should be taken with them, but pretending you're going to court and having novel notes where you diligently read the patient a 15 page consent form for some minor thing is more suspicious than anything. Generalities like risks, benefits, etc..gives you leeway to describe your standard practices and what you might say to a similar pt, without having to have a specific recollection.

nephron wrote:

It’s very true when they say that if it wasn’t written down, it didn’t happen.

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This is in no way true, and is literally one of the dumbest things I hear doctors pushing. Almost everything you do isnt written down, in a visit, a procedure, etc...check for yourself by reading to see if your note took as long as the surgery, anyways, it doesnt matter, you're talking to people who in no way assume if you didnt write it down it didnt happen. Its absurd.

Neither is the converse true, you cant just write stuff down you didnt do or say and that be your defense nor will it be assumed to be true. Writing things down doesnt make them true.

This is actually a harmful myth to be propagating and people really need to stop repeating it. Also the opinion of a top med mal attorney in california, who I have personally witness destroy the idea, and the opposing side in trial.

[Anne]

MPMD's comments might apply in the ER but the Chart 1 style of documention wouldn't work in my area--if you are in an area where continuity of care matters, thorough documentation helps with that. Although I agree, chart 2 is pretty crappy--while it has a few salient pieces of info the word efficiency is terrible.

I see a lot of patients with complex chronic conditions who have had numerous treatment trials with variable success. If their treatment course isn't well documented a lot of time can be wasted considering the same things over again.

Also, there is interesting research in predictive factors for what acute pain will turn into chronic pain. A review of those risk factors at the time of intitial fracture treatment could help identify who needs closer f/u, etc. and might prevent that patient from being in my clinic 5 years later with chronic intractable wrist pain

That being said, there is a way to be efficiently detailed. I see a lot of resident notes that take 3-4x the words/space that I would use to convey the same info. That makes f/u more difficult, as you are scanning a book of fluff trying to find the salient points.

[wideopenspaces]

I used to type while I talked to patients and note was done when they left. But I spent a lot of time on mychart messages at my last job. So many messages! At the new job, I am only seeing a few patients a week but should increase to a couple a day, hopefully. Not a lot to do outside of notes, but the computers are so slow in the clinic rooms that I often write up the notes in my personal office after I talk to patients. Still not breaking the bank from a time perspective.

[nephron]

I spend much more time on my patient notes then my partners do.  I used to always tell people that we chart for 1.  reimbursement  2.  communicate to other physicians  3.  medico-legal protection.  The 3rd one, medico-legal one, is the one most benefited by additional charting.  I've been through one lawsuit, I consider it a frivolous lawsuit, but by the time that went to trial, it was ~5 years after the incident and all anyone had to go on was what was written down.   It's very true when they say that if it wasn't written down, it didn't happen.  At my trial, they went note by note, projected them onto a projector screen, and asked the doctors to explain to the jury what they meant in each note.   A quick note may be sufficient for reimbursement or communication, but I think that a longer verbose note that explains your rationale and thought process goes a much longer way in a courtroom.  A good example would be like the patient who fell, if you just document patient fell, wrist hurt, but then felt better with ice, told her to come back if any increase in pain, loss of sensation, etc, and it turns out that the patient had a fracture that they didn't find on x-ray, you will do much better in court then if you just have a quick blurb stating patient fell, right wrist pain.   No one will believe you 5 years later in a courtroom if you say you remember the patient telling you that they thought that their wrist felt better and wanted to go home and you warned about the missing a fracture if you don't put in the chart.  A lot of wasted time charting for relatively rare events, but I think that people have to remember that a good chart can be the difference between a lawyer even filing a case vs passing up a case when they review the charts.