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.
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.