You've all heard the saying, if you didn't document it, it didn't happen. Right? Wrong. If I had a bowl movement today and didn't write about it, it still happened. With that in mind, a reader of The Happy Hospitalist brought up an interesting point of discussion. What should be documented in a hospital progress note and what is a waste of time? How should we be writing progress notes in the hospital? Here is the reader's question in full:
I'm a 3rd year resident in internal medicine, going on to be a full time hospitalist when I graduate this year. I had a question about documentation that we've struggled with at my residency program and one which I've failed to get a consistent answer to, even from my otherwise brilliant program director.
As medical students, we get trained to write reams and reams of stuff in our assessment and plan section, and as interns and residents, the amount we are expected to write is reduced, but I for one have not received proper direction as to how much the narrative should be whittled down. Let me give you an example:
1. Febrile state with new onset murmur: At the time, infective endocarditis needs to be ruled out. Blood cultures from yesterday still pending. TTE ordered today. Vancomycin Day two started for empiric treatment. Patient currently presumed septic based on fever and white count. otherwise VSS. Will order TEE if TTE negative. Will consider ID consult.
That is one way to say it, and our program did not discourage this verbosity, and indeed I know residents that would have written even more. Another way to say it is as follows:
1. Suspected IE: Vanco D2. Await Echo, CX.
Here you have to extremes of documentation. In my residency program, the patient load has more than doubled in the 2 and a half years I've been here and our program is struggling to keep up. One of the places I feel we need more direction on is what the appropriate amount of documentation needed is. I don't mean from a billing perspective, I mean from the perspective of effective communication to other members of the health care team. Our hospital is a big one, and we don't always run into the other members of the medical team and so need to put our thoughts down in a communicable way.
What is your take on how much detail needs to go into notes to communicate well? As a hospitalist, I need to figure out how to do this efficiently.
Most doctors have been trained on how to write a S.O.A.P. note for their hospital rounds.
You can find a good explanation in my original coding post on billing a CPT® 99231. If you think the chart is a way for doctors to communicate with each other, you are sadly mistaken. Those years have long disappeared. The chart is for lawyers and insurance companies. You will soon learn out in the real world that reading another physician's charting is a mystery in and of itself. There is no point. If you have a question, call them. My suggestion to you? Get in the habit of writing "See orders" as your plan. That is your plan. That is all that matters. That's all you need to write. It takes care of the insurance companies by linking your orders as your medical decision making component of your complexity. Regarding all the other garbage being written?
- Nobody is going to read it
- Nobody cares. See #1.
Make it simple. If I need a reminder of my thought process going forward, I may write little comments about "consider x or evaluate y if no better". But I write it for me, not others because I know nobody else really cares what I write and if they have questions or concerns about my management plan, they will call me directly. Your orders ARE your plan. Forget all the other nonsense. You are just killing trees and wasting your time.