Clinician documentation is everything. It tells the story of the patient’s current condition and what is being done to fix it. Against it patients’ charts are coded for billing and reimbursement. Upon it insurance companies can deny level of care or specific DRGs. And upon it malpractice lawyers build a prosecution against clinicians. Like I said, clinician documentation is everything.
In the past, brevity was lauded. In fact, I myself was praised by my colleagues for the brevity of my notes: they were short and to the point. Times have changed. Brevity can no longer suffice.
I recently wrote an appeal on a case where the insurance company denied a diagnosis of type II myocardial infarction because the doctor documented:
“Elevated troponin. Likely type 2.”
Now, every clinician understands what this means. Yet, the insurance company wrote in their denial that there is no such diagnosis as “Type 2” and denied the DRG, claiming that they therefore overpaid the hospital and were demanding a refund. It was so very obnoxious.
At the same time, the doctor in this case gave the insurance company the knife with which it stabbed the hospital in the back because he did not write two words: “myocardial infarction.”
I had a similar experience: an insurance company actually denied the diagnosis of acute respiratory failure in a kid who got intubated for cardiac arrest in his home. They had the audacity to claim that “airway protection,” which was the reason documented for why the kid had acute respiratory failure, is not a diagnosis. It was one of the most egregious denials I have ever appealed. Again, the clinicians in this case gave the insurance company the knife. Brevity beware.
The Centers for Medicare and Medicaid Services changed the documentation rules in January of this year, de-emphasizing history and examination and strongly emphasizing medical decision making. I lauded the changes.
Finally, I don’t have to worry about documenting silly, irrelevant things like a “review of systems,” and I can focus on what matters: what I feel is wrong with my patient and what I am doing about it. And brevity can no longer suffice.
No longer can we say: “UTI. Continue antibiotics.” No longer can we say: “Elevated troponin, likely type 2.” No longer can we say, “Patient intubated for airway protection.”
We need to answer the questions: how is the UTI? Is it better? Is it worse? How is the patient responding to treatment? Why aren’t you discharging the patient when the vital signs and labs all look good? Why are you admitting the patient to the hospital in the first place?
We need to write, “Elevated troponin is most likely secondary to type 2 myocardial infarction”; we need to write, “Patient intubated and placed on invasive mechanical ventilation due to the inability to maintain an open airway due to acute metabolic encephalopathy.” Brevity in our documentation can no longer be best practice.
When I give lectures to clinician trainees and practicing clinicians alike, I say the same thing: if your documentation is poor, prepare to have a difficult time. This is true when doing a Peer-to-Peer discussion with an insurance company Medical Director, or when appealing a denial, or most distressingly, in a medical malpractice case. Poor documentation hurts everyone involved, and it can even compromise patient care.
Will this likely take more of our time? Yes. And it is essential that we take this extra time to make our documentation as robust as possible. CMS has tried to help by changing the rules so we can take more time on medical decision making. We need to take advantage of this. We can no longer afford to have brief notes that say nothing, just like we absolutely can no longer afford to have a note that is 15 pages long and also say nothing.
We need to up our documentation game to a whole new level. Brevity can no longer cut it, clinicians. Brevity beware.
