Could being on Twitter make you a better note-writer? We certainly think so! That was one of the many hot takes from February’s #JHMChat, with special guests Drs. Blair Golden, Robert Centor, and Andrew Olson. We explored the most fundamental question in the electronic health record (EHR): what makes a good note?
Honest question, has being on Twitter helped you write more concise clinical notes?#JHMChat
For me, the answer is absolutely. https://t.co/Rvgt0vl56F
— Charlie M. Wray, DO, MS (@WrayCharles) February 22, 2022
Early in the night, Drs. Dhruv Srinivasachar and Robert Centor enlightened us to the origins of the problem oriented medical record by invoking Dr. Larry Weed and his 1971 grand rounds.
A central issue with notes is that they serve many purposes. They document the patient’s hospital stay, serve as a tool to think through differentials, inform medical billing, and most importantly, communicate with the care team and with the patient.
As if our notes didn’t already fall short, their limitations were underscored when the 21st Century Cures Act made clinical notes more accessible to patients and families. Many hospitalists confirmed that this has changed their approach to notes.
#JHMChat A3: I DO try to keep my patients in mind, as if they’re looking at the notes, more so now than I used to. It makes me remember person-first language vs. biased language. How do I convey the challenges of this hospitalization as part of a partnership with my patient?
— Joseph “Dr. Joe” Thomas, MD (@DocWithBowtie) February 22, 2022
Always writing as if the patient or their family might be reading. Further reminder to avoid judgmental or stigmatizing language like “poor historian” or “non-compliant.” Important to reinforce with trainees. #JHMChat
— Eric Schultz (@ericschul) February 22, 2022
Many bemoaned billing requirements that reward medical complexity, which often makes notes unreadable for patients and families. Billing requirements also contribute to burnout among physicians. Dr. Centor noted that the only way to address this will be to change our documentation requirements.
#UncleBob – only changing documentation requirements will matter. This has happened in the outpatient note, yet physicians have not yet changed. Vexing problem.#JHMChat https://t.co/YVUSf7t4XA
— Robert Centor (@medrants) February 22, 2022
There appeared to be almost universal agreement on the disgust with “note bloat” — you know, when notes are filled every lab and radiology read from the hospitalization.
Seeing all these great responses makes me wonder – what if we were to “invent” the note in the EHR era? We we wouldn’t document much “data” at all since it is elsewhere. We used to do that because it was hard to find, but now it is our thinking/rationale that matters. #JHMChat
— Andrew Olson, MD (@andrewolsonmd) February 22, 2022
Yichi Zhang, a medical student at Tulane, shared that his notes help him to translate learned schemas into concrete clinical reasoning. But do we routinely teach students and residents how to use their notes in this way? Many participants, including Dr. Subha Airan-Javia from the University of Pennsylvania and Dr. Sherine Salib of Dell Medical School said that the medical education community needs to be more intentional about teaching clinical documentation to our learners.
A1.
As a #MedEd community, we are not intentional enough about teaching documentation skills. We assume that it’s a skill that learners can pick up..
We need a “clinical documentation curriculum”. After all, this is a huge part of what physicians do every day.#JHMChat
— Sherine Salib (@DrSherineSalib) February 22, 2022
A1: From a student’s perspective, the primary purpose of my notes is to help translate my learned schemas into something more concrete. It helps me practice elaborating my clinical reasoning and is also a great platform for residents/attendings to give regular feedback! #JHMChat
— Yichi Zhang (???) (@YichiZTulane) February 22, 2022
Many participants shared innovations to transform the note writing process. Dr. Vinny Arora of the University of Chicago reported that her institution created a discharge summary that can be shared among multiple people, so that daily notes aren’t seen as “must contain everything”. Dr. Subha Airan-Javia described her experience creating a collaborative wiki version of documentation that has been adopted at her institution.
In addition to these ideas, many participants offered other concrete tips to make your notes better:
- Dr. Centor suggested putting the assessment and plan first.
- Dr. Bijay Acharya emphasized deleting your differential as new data comes in and you are able to commit to a diagnosis. He also proposed changing the diagnosis from symptoms to specific disease code as more data returns.
- Dr. Mark Shapiro offered advice specifically for writing discharge summaries. He pretends he is the person reading it and asks, “What do I want/need to see? What is not relevant/distracting? What would make me feel frustrated to not have included?”
Exactly!! I tell my trainees their assessments must include if things are better, worse or the same in comparison to the prior day’s documentation. #jhmchat
— Anika Kumar, MD (she/her) (@freckledpedidoc) February 22, 2022
Teach providers how to write effective notes that require minimal daily editing! e.g. no doses or frequency unless strong reason for it, no words like “yesterday” or “tomorrow” but actual dates #JHMchat
— Sebastian Suarez, MD, MPH (@sebsuarezmd) February 22, 2022
So, can your notes do it all? This #JHMChat discussion proved that the EHR documentation is challenging even for the most seasoned clinicians. Despite this, the note-writing landscape is ripe for innovation! If you missed out on this #JHMChat, don’t worry! The next chat is coming up on Monday March 21st at 9pm ET and will explore some of our most popular Things We Do For No Reason™. We’re talking fluid restriction in heart failure, holding metformin in the hospital, and using race in the HPI. Don’t miss it!
EHR’s that I saw 8 years ago before I retired, were lists of everything. No narrative to allow you to put your thoughts together to allow the synthesis of a diagnosis. Cut and Past of a past note made the problem of understanding what was going on even worse. The important stuff was buried beneath the filler to get a higher billing code. The need to put in the filler came, not from the doctors’ needs, but from the insurance company or medicare. And on top of this, it took even longer to write it and review it. My own internist would go home, eat dinner, then log back in to finish his charts. I also know many older doctors who retired rather than deal with the EHR. The had money and took their knowledge to the local charity health care program where they had a person who dealt with the computer. Old fashioned pen and paper was so much easier.