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

If you didn't document it, it didn't happen.  These are 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 paid vs not getting paid 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 documenting honestly or dishonestly.  It's not a matter of writing  doctor notes or denying patients trying to take advantage of the system.  One would hope the record is accurate, but it can never be an all inclusive picture of the entire cogitative experience.   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 about 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.  The patient loses.

This system results in a lack of trust among all the players. Nobody believes anybody.  It's like Congress.  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 EMR  charting.  Health care is an act.  My orders?  That's health care. I write an order to deliver a medication or to perform an ultrasound or to draw laboratories or to get home health care or to have physical therapy to evaluate.

That's health care. It requires a physician's order to be implemented. We physicians are ultimately in control of a vast pool of health care dollars by way of our decision making process, collaboration and communication which government agencies license us with the  right to provide by way of our education and our certification and fo which our respective societies bring faith to the public by way of our board certification.  There is a  granting per say of our educational abilities to perform our jobs to the best of our current medical understanding.  We make daily decisions to consume health care dollars by way of our orders.   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.  I could not possible document every spoken word during my day:
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.

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. 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 is important and what is not  unimportant.
It would be a physical impossibility to document everything that takes place, whether that be the patient's words, the nurse's words or my words.  You get the drift.  What a doctor chooses to document at that brief period of time is quite a subjective interpretation of objective 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 due to the impossibility of that expectation.  This has nothing to do with medical care or the service provided or 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 paid.  

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 surgeon's subjective interpretation of that day's 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.  They get paid a global fee to provide surgical services. 

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 with longer and more inclusive notes.  In general, one only needs to look at a hospitalist note  to understand where I'm coming from.  What's the take home message?   Just because it wasn't documented, doesn't mean it didn't happen.  

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6 Outbursts:

  1. I am SO going to use this post the next time someone makes that stupid statement.
    Often wondered about bringing a tape recorder in the rooms and recording everything that happened as if at a trial, then saving the mp3 file indefinitely.
    Wonder how that would fly with the feds.

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  2. Excellent post! I never realized just how complicated everything is for you docs until I started reading the med blogs last year. After reading some of the private docs blogs it seems they need an MBA too when it comes to running their practices.

    I had a lot of ureteral procedures in the OR in 2006. I am thinking of one particular day in the beginning where urodoc had to do a lot of work. when I reviewed the EOB I thought my insurance co made a mistake and so I called them. They were paying a lot less than what urodoc billed for. They said it wasn't a mistake. Then when I saw the doc I mentioned it to him in case it was a coding error. (I have a PPO plan and it has a quick turn around time for payments and we have been happy with the plan.)The doc thanked me but indicated that is what plans do. Frankly...I don't blame surgeons if they document briefly. After all the work they do and it is so important for the patient...i just don't understand how the system can treat surgeons that way...I really don't. Where's the incentive? My understanding is that doctors join these plans because they get more pts. Sorry ..I digressed a bit. I am just in awe of all the responsibility doctors have on all fronts.

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  3. Wow, how familiar...found you via Fat Doctor, & started reading about CPT, E&M codes, etc. It was like an odd flashback to my schooling in HIM. And...one of their favorite maxims was: "Not documented, not done.". How funny is that! Of course, once I got a good look at the actual contents of medical records, that statement became a bit troublesome. We are still human, after all! (Though JCAHO, CMS, and private insurers would like to think otherwise, given how the whole system works--or doesn't, depending on your perspective!)

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  4. Excellent post! I recall as an impressionable intern, being taught by a less-than-stellar senior resident the ludicrous premise that a good dictated operative report should be so detailed that a reader would be able to reproduce exactly what you did. After all my fellow interns and I wasted countless stress-filled hours dictating detailed op notes ie "all areas of active bleeding were cauterized until excellent hemostasis was noted. Areas not controlled by cautery were rendered hemostatic with a suture of 2-0 Vicryl" as opposed to what? "we just closed her up and went home?", we finally saw the error of our ways and became exponentially more efficient in our dicatations without compromising patient care one bit. The most important parts of an operative report are the descriptive findings. When I review op notes patients bring from other doctors, I'm most concerned about how things looked inside at the time, during the last moment that anyone had the luxury of directly inspecting internally, not what instruments they used to dissect with.

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  5. I've fantasized saying to these dolts "How about I emasculate you, but don't document it?"

    Great post.

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  6. You da man. Brilliant.

    But then again, since THAT wasn't documented...

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