The following is a guest blog post by Dr. Michael West. I recently met Dr. West and was really impressed with his approach to EHR. After reading a few of his comments on the site, I asked if he was interested in doing some guest blog posts. This is the first of what I hope will be many more blog posts by Dr. West.
Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.
When, I was in residency at a large health system in Pennsylvania, several of the residents and interns got into the habit of templating hospital notes on their home computers the night before they would go in to see patients who were chronic players with multiple medical problems who would often stay for long times in the hospital. I’ll openly admit that I was one of the many who bought into the perceived need to make things more efficient in order to get out of the hospital sooner and have a better home life. The concept was simple: design a pre-templated note for each chronic patient, detailing the plans (which would rarely, if ever, change), and then save it and mass produce at will. Of course, this did not go over well with our purist administration who were in charge of ensuring the highest quality, authentic notes for each patient on each day. In their correctness, they noted that sometimes these notes would be put into patient charts without those small changes that would, in fact, take place from day to day, thus resulting in erroneous documentation.
Now, years later, in the world of EHRs, there seems to be a push-back against the “cut and paste” concept. I know this is out there for two reasons: one, because I have read a blog or two citing it, and two, because I have enjoyed doing it myself. In the cut-and-paste world of computerized documentation, it’s addictively efficient. Gutenberg, the inventor of the printing press which allowed mass production of books and changed the world, would be proud. The responsibility for using such powerful efficiency does fall to the individual health provider to carefully review, edit, add and subtract documentation to ensure current accuracy. However, if done correctly, it allows careful preservation of a summary of what came before.
For this, I have some personal recommendations. First, actually DO the editing, don’t just cut, paste, and sign. Second, go back and refine the previous note for word choice and economy. Otherwise, you will create endless run-on documentation that is unprofessional in appearance and a burden for your colleagues to wade through later. From a billing perspective, it facilitates and supports that you have actually reviewed the patient’s previous history rather than just asking them what’s going on today. I find that cutting and pasting the old plan prompts me to consider everything I was trying to accomplish after the last visit and promotes holding the patient accountable for getting all of their previous orders accomplished. If something was not followed up on by the patient despite my recommendation, then this definitely gets documented in the current note. And then, of course, I ask them to “try, try again.”
I find nothing inherently wrong in this process and my patients get the benefits of an accurate portrayal and review of their conditions with appropriate follow up evaluation and managent. So cut, paste, edit, and save your evenings for yourself, rather than dictating entirely new notes that regurgitate the same old information. Work smart, while still working hard.