Until the advent of electronic health records (EHRs), health care providers relied largely on medical transcription companies to document office visits and consultations. Today, these outsourcing companies provide digital medical transcription services, converting audio recordings of physician dictation into accurate and well-formatted notes for the EHR. Clear and accurate medical notes support clinical decision-making and patient care. Experts have made several recommendations to improve the consult note in the electronic record system.
A medical consultation allows the physicians to assess the patient’s problems and concerns and to diagnose their illness. Patients are asked questions about their condition and allowed to provide answers in their own way. Many patients have more than one concern to discuss. Best practice is to avoid interrupting the patient as this may prevent disclosure of full information. Once the problems have been discussed, the physician should repeat a summary back to them to ensure that they have understood the patient correctly. Many physicians use a medical transcription service to maintain eye contact with the patient and avoid becoming too immersed in EHR data entry.
However, experts point out that notes that physicians write to document medical consultations are too long. This is because the Center for Medicare and Medicaid Services (CMS) and other third-party payers tie their assessment of the amount of work done, and hence the valuation of the physician’s work to detailed documentation. In an article published in Cleveland Clinic Journal of Medicine in 2015, K.K. Venkat, MD describes the problem as follows:
- To meet paper requirements, physicians include detailed documentation of the history (present, past medical, past surgical, medications, allergies, social, and family), review of systems, and physical examination in the consult note.
- The above information is already in the medical record and repeating it in the consult note leads to duplication of information.
- As this part of the consult note is hardly ever read, time spent on repeating information is wasted time.
- EMRs have made it easier for the provider to create lengthy consult notes by checking boxes in templates and copying and pasting from other parts of the electronic record.
- The educational value of the consultation depends on consultant’s critical reasoning, but the assessment and recommendations section in the consult note is too short.
The article recommends keeping consult notes in the EHR “short and sweet”.
A 2015 Medscape report also highlighted the features of succinct and effective consult notes. According to the author, the consultant’s note that addresses patient care issues, should be concise, brief, not duplicative, logically structured, and offer educational value. However, the problem is that such a note would not be “optimally reimbursed” by today’s payers. According to the article, payers should recognize and reward critical reasoning skills rather than the length of the consult and the ability to copy and paste or reproduce information. Done correctly, a consultant’s note can be educational, drive the requesting and the providing physicians or other staff to think comprehensively, improve patient care and outcomes, and reduce unnecessary testing or treatment.
A study published in The American Journal of Medicinein 2018 noted that shortening EHR case notes can ease the EHR burden and mitigate physician stress and burnout. According to the researchers, EHRs contribute to lack of enthusiasm, lack of accomplishment, and cynicism – the three main causes of physician burnout (www.healthleadersmedia.com).
The researchers said that case notes can be shorter without compromising the quality of the information and recommended the following best practices for taking shorter case notes:
- Record the patient’s presenting complaint and all relevant data that helps the physician formulate the differential diagnosis (DDx) and a plan for concluding the visit.
- Relevant data can include testing, consultation, procedures, or medications.
- Any additional documentation can affect the quality of care as the physician has to enter data and populate the record with templated information that complicate and mask the key patient care issues the next time a physician sees the chart or the patient.
- Take notes while asking questions and look at the patient while performing EHR data entry.
- Have a template that auto-populates medications, vital signs, and simple exams.
- Use separate templates for children and gynecological exams.
- Skip templates and manually enter problems or assessments with alternative diagnoses when making assessments or diagnoses.
- State why preferred and alternative diagnoses are possible, which will help explain diagnostic reasoning when other providers view the record.
“The hours spent cloning notes in a mandated doctor-computer relationship leaves the physician unable to experience the best part of being a doctor… Rational people should feel cynical if the institutional accomplishment for the day is to produce 20 cloned medical records,” wrote the researchers.