If You Didn't Document It, It Didn't Happen.

That is the famous last words of the prosecuting attorney as he stares at you up in the hot seat of that court of law.
That's what the lawyers want you to believe.

It didn't happen.

That's what they want the public to believe.

It didn't happen.

In fact, documentation is much more a function of getting payed vs not getting payed than did it happen or didn't it happen. And this concept reverberates across primary care, specialty and sub specialty care with universal conformity. It has nothing to do with falsifying the record. One would hope the record is accurate (whether or not it is is another blog entry). But it is not an all inclusive record of fact. It is but a brief period in time. A subjective period in time.

We doctors, in order to make our living, have been turned into Medicare lemmings and I believe it brings incredible loss of productivity by deferring time, money and resources from patient care to patient documentation:

To appease the lawyers. It didn't happen. You're at fault
To appease the insurance companies. It didn't happen. You wont get paid
To appease the government. It didn't happen. Your quality is poor.

Guess who's missing from that population of people.

The patient.

The group you are there to help has the least incentive to care what you write. They just want to get better. They have absolutely no idea of how incredibly complex the system of documentation is in order to get paid. To be considered "quality care" To be considered ass covering. To be considered a service at all.

The patient loses. Why is that a constant theme as I see it in the current delivery of health dollars?

This system results in a lack of trust among all the players. Nobody believes anybody.

It's like Congress.

And the patient continues to lose. No wonder all the stress, anxiety and distrust is present in our patients.

Moving on...


There are thousands of things I do in my life every day, that I don't document.

I woke up in the morning.
I turned off my alarm.
I took a shower.
I brushed my teeth.
I started my car
I drove to work.

The list of things I do on a daily basis that are forever undocumented is endless.

The reality is, every one of those things happened, whether I wrote it down or not.

I don't get paid to write it down.

Correlate this to "medical charting".

Health care is an act.

My orders. That's health care. I write an order to deliver a medication. To perform an ultrasound. To draw laboratories. To get home health care.

To have physical therapy evaluate.

That's health care. It requires a physicians order to be "consumed". We physicians are ultimately in control of a vast pool of health care delivery dollars by way of our decision making process, collaboration, communication which we earned the right to perform by way of our education and our certification.

Which our respective societies bring faith to the public by way of our "board certification".

A guarantee, per say of our educational abilities to perform our jobs to the best of our current medical understanding.
We make the decisions to consume health care dollars (for the most part).


You can't deny that.

It happened. And the record proves it.

It is an order.

That's the only guaranteed provided service documented.

The rest of physician documentation is for the most part a subjective determination of the period of time that requires truncated versions for the written record.

My communication with physicians, nurses, radiology, techs.
My interpretation and analysis of available data
My thought processes from start to finish
My internal conflicts with my decision making. So often nothing is black and white.

What I chose to document as fact for the written record is open to my interpretation of what is important and what isn't. Subjective interpretatation of objective data.

All players are trying to turn my subjective into objective.

Payers
Government
Lawyers.

The human body is not an object. It is a project.

A project filled with largely subjective interpretation of objective data.

I can never and will never be expected to document it all. 100%. A 30 minute visit with a patient would require hours and hours of written record. It simply will never happen.

What I chose to document is a function of my ability to weed out what I feel are important and what are unimportant interactions, actions, conversations.

It would be a physical impossibility to document everything that takes place. Whether it be patients words, nurses words, my words, all data results.

You get the drift.

What a doctor chooses to document at that brief period of time is quite a subjective interpretation of objective medicine.

This is the The Art Of Medicine.

What I see in the hospital for documentation is a direct result of the economic reimbursement policies of Medicare.

Documentation is a brief period in time of the encounter, not all inclusive do to the impossibility of that expectation
This has nothing to do with medical care. The services provided. The time involved.

It is simple the written record.

The written word is but a brief synopsis by the physician.

A synopsis which often times is driven by the need to document to get paid

It is not the only truth. It is the version of truth required to get payed.
Documentation is strongly associated with money.

That is a medical fact. And I see it everyday of my life.

Medicine should be practiced and documented solely on the basis of the spectrum of medicine. And unfortunately, it has become a practice of legalese. A practice of economics.

How do I protect my ass.
How do I get paid
How do I get perceived as "quality"

I have the classic example of how economics affects documentation.

The idea of a Global Fee for surgery. One Surgery. One Fee.

Spend 1 week in the hospital. See the patient every day? One Surgery. One Fee

Spend 1 hour in the hospital. See the patient one day? Same Surgery. Same Fee.


As an internist, I have the opportunity to assist in the medical care of surgical patients all the time. It's called surgical comanagement and is an exploding conceptual idea in hospitalist medicine.

I have the opportunity to read charts. Thousands of them on my many patients.

One concept is universal.

Absolute minimal documentation by surgeons. Routinely 3-4 lines. A surgeons subjective interpretation of that days data.

I can guarantee you that surgeons are smart.

Damn smart.

And their 3-4 sentence notes are not indicative of their lack of knowledge or understanding of the patients care or recovery.

They simply do not get paid to write their notes.

Their global fee is all inclusive. And once the surgery is performed, they are paid. It is the law of diminishing return to spend 15-20 minutes documenting in the chart, every day. Day after day.

What would happen if Medicare suddenly abolished the concept of Global fee.

I can assure you that the style of interpretation and subjective interpretation of objective data would suddenly shift. Longer notes. More inclusive notes.

One only need look at a hospitalist note (in general) to understand where I'm coming from.

Take home message. Just because it wasn't documented, doesn't mean it didn't happen.

It just wasn't worth the time to get paid.