Documenting Patient Data in the EHR

March 31, 2015

The ability to document in the EHR is a blessing and a curse. My fear is to produce a note that has a lot of words, but says nothing of substance.

Many years ago, my first preceptor taught me how to write a SOAP note. I started with the subjective - what the patient described in her own words. The objective described my physical exam findings, vital signs, and diagnostic studies.  Next, I was expected to develop a thoughtful assessment - one which combined the subjective complaint, my objective findings, and application of medical knowledge. The assessment naturally led into a well-reasoned plan of care. I've had numerous notes reviewed over the years - some by interns or residents who helped me develop more succinct documentation, some by attendings responsible for assigning me a grade for the rotation, and many by nurses and other physicians involved in the care of my patients.

Despite being out of medical school for more than a decade, I still go back to that first lesson to develop the notes that document the care that I provide. I often reject the standard template in order to tell my patient's story in the subjective. Despite the ease of documenting an exam in the EHR, I pause to make sure that I don't over-document what I didn't do or simply default and exam to normal. At the conclusion of the note, I try to capture what I am thinking both for the benefit of those taking care of the patient next, and for my own memory. My fear is to produce a note that has a lot of words, a few numbers thrown in for good measure, and numerous hyperlinks to all sorts of random and useless data which, in the end, says nothing of substance.

The ability to document so many things in the EHR is a blessing and a curse. Remember the days of chart reviews? Another physician would read your patients' charts to make sure you were doing the right thing. Now, this type of review is done primarily by the EHR itself. You may have written paragraphs about your conversation urging the patient to quit smoking, but if the right box isn't checked, you haven't done the counseling in the eyes of the computer. This type of chart review is a form of data mining that is increasingly tied to how we get paid. Not because the care we provide is poor, just that it is considered to be poorly documented.

I struggle with this. The office visit note is for the primary purpose of documenting the patient's care. Everything else is secondary. Yes, the documentation can be used to assure high-quality, high-value care. Yes, it can provide data to fill in an Excel spreadsheet or population health database. And yes, it helps insurers determine if they are getting what they are paying for. However, when the main purpose of the documentation is to provide data that is secondary to the patient sitting in your office receiving care, I hesitate.

The information available to us is amazing and overwhelming and frightening and vast. I can Google pretty much any topic and get more information in three seconds than it used to take in three hours (or days) to retrieve at the library. I love this convenience and think the best parts of it should be leveraged to provide top-notch healthcare. Yet, a big part of me longs for the days of a pen and paper when all I needed to worry about was getting enough documented that I could pick up where we last left off at the next visit.