Any physician, and certainly any emergency physician, may have scratched his or her head over this question at one time or another. I can remember, not only in my early years an ED doc, but also during a period in which I ran an office as a youngster, the way in which notes were made. “Cough. Sounds like bronchitis. Try antibiotic (xxx); see in a week.” For the office, those were even more words than were commonly seen. And for the ED, where the “chart” –from beginning to end-- was handwritten on NCR multiply paper, it was not much different: “Chest pain; EKG – acute anterior ST elevation – admit to CCU.” Sure, I’m dating myself, as it was before cath labs (!) and the presence of computer terminals at every desk. But some of you remember, and the rest…well, you are just going to have to take our word for it!
Now, it is of value to ask: “how did all this get started?” “Why does so much of my time and energy go into creating documents?” “ I could be using those resources to communicate with patients, discuss care, consider and think about the interventions and treatments being applied.” If one looks historically, several fundamental purposes for putting pen to paper existed throughout the centuries in which medicine, as a science and as a profession, came to exist.
Always however, those purposes were for communication.
Why Do We Document
- Donald Kamens, MD, FACEP, FAAEM, Founder
At bottom, a physician was communicating to himself/herself. When the patient returned—if the patient returned—there would thus be a note to refresh the memory on what was previously thought, and what was done. Some physicians, and I knew a few, made no notes (!). Their memory was of a class by itself, and each of their patients was like a personal family member whose whole history lived in their minds and hearts indelibly. Rare birds, these were, and certainly quite extinct.
Those practitioners who worked in larger offices wrote also to communicate with a partner or associate who may wind up caring for the patient at another time. A good rationale, and sometimes, when considered, required seven or eight words, instead of just two.
And then there were the needs of research. Research always required the accumulation of more data, and so those thus engaged needed to document more fully. We can attribute a good deal of the foundations of our medical knowledge to those who, like William Harvey some 400 years ago made copious notes. And yet even he admonished “not to enter into too much detail.” If only Harvey’s prescient counsel could be followed today. For what do we have? It has run amuck. Why? Well, many of us think that the first incursion was ascension of malpractice defense. Malpractice litigation appeared for the first time in the US during the middle to the end of the 19th century (JAMA. 2000 Apr 5;283(13):1731-7. N J Med. 2003 Jul-Aug; 100(7-8):21-5. http://www.nejm.org/doi/pdf/10.1056/NEJMhpr035470).
Nevertheless, it was really only in the 20th century that defense of such litigation became a day-to-day consideration for physicians. As a result of the underlying process, records were subpoenaed, notes were scoured by plaintiff’s attorneys, and physicians were called-to-carpet for omissions or commissions of words rather than omissions or commissions of action or inaction. Note the result, the word became the foundation upon which litigation was built. Hence, attention to words became an effort-requiring part of keeping the center of one’s practice free, or relatively free, from the efforts of these to extract money from a realm which was once quite purely and completely devoted to caring for patients. Note that what was once a few word note, became, defensively, a more extensive pronouncement, sometimes a diatribe. All in defense of some anticipated litigation.
On the heels of this incursion into the formerly somewhat word free realm of medicine, came a new demand for justification of reimbursement from third party payers, in particular CMS-Medicare. Here, physicians were formerly jotting down just a bit, now writing with a view toward building a potential defense, and along comes various forms of pay-for-performance initiatives, such as DRGs and others to really crank up the word requirements.
Thus “performance” was tied to what was written down, noted, charted. And the medical record, thus became the reflection of medical activity. Whether it was accurate or not, is another matter, still if it was not written, “it was not done.” And if it was not done, it was not paid.
It does not take much therefore to see why we document, and thus how the EHR has become the now centrally increasing mechanism for creating a record upon which the life of a practice will ultimately rest. A good record = a defensible record. A good record = a reimbursable record. Hence we document to keep our heads above water, but whether we do so, truly, for the sake of good patient care, is really another question entirely.
In the end, we do the best we can, within the circumstances in which we exist. So we will likely be documenting on every patient, and perhaps wincing a bit along the way. Still, in the modern practice of medicine it is as necessary as air and water to survival. So make the best of it. Look for ease of use. Employ paper if you can get away with it. But if not, simple user interfaces are a key to a good life in the ED or clinic. You should never need to spend more than a few minutes after a shift to complete your day’s documentation. If so, find a fix. Documentation of patient care is a beast that has evolved out of control for many decades, but wrestling with it is something we have to do in a way that tames its excesses, and keeps it true purposes in perspective.