Getting Down to Brass Tacks with Providers About Documentation

When I was a medical student in the late 90s, one of my attendings sectioned off a third of the sheet of paper in the medical record before me and instructed my note could not be larger than that area.  Overwhelmed with a desire to capture every point about the patient’s story and condition which I considered of interest, I proceeded to write in tiny text so two lines fit into every one printed on the lined paper.  While this memory makes me chuckle, it also reminds me of one reason why we continue to have such an issue with inadequate provider notes.

Back in the day, brevity in medical documentation was practically a badge of honor.  You’ll be hard-pressed to find a physician between the ages of 40 and 80 who doesn’t remember at least one “legend” who kept a rolodex in their clinic office with a single index card per patient.  Not per patient encounter – PER PATIENT.  And, let’s be honest, who hasn’t rolled their eyes at a hospital surgical note which is a single sentence long? 

Documentation started out as a record of patient condition for the documenters themselves – reminders of what they saw and addressed the visit before.  With the rise of sub-specialization and team-approach medicine, office and hospital notes evolved into a type of communication using abbreviations and symbols which required special education to decipher.  At the time, passing information between practitioners was of primary importance and the main reason for documentation.  Everyone was on the same page (literally, before the development of electronic health records), and was kept in the loop with the plan for the patient. 

When the purpose of documentation melded into the support behind reimbursement and quality monitoring, no one really explained this shift to the doctors and other providers.  I stopped practicing clinically in 2014 and it was about a year before that when my group of pediatric hospitalists first spoke with someone “in the billing department” about specificity of documentation for patients with asthma and avoiding the term “urosepsis.”  What was the reasoning behind this direction?  “To make sure the documentation is as specific as it can be.”  As you might expect, my colleagues and I were unimpressed.  In fact, I did not understand what was REALLY being said until after I became a physician advisor working closely with utilization management and clinical documentation integrity teams. 

Why?  Because no one took the message down to brass tacks.  Provider terms do not equate to coding terms and without proper coding, there is no proper payment to the hospital.  Without proper payment to the hospital, services our patients need can’t be afforded.  Without the ability to provide services our patients need, they would divert elsewhere and ultimately, the hospital will close.  And, we haven’t even touched on quality and things like expected length of stay and outcomes….

My hope is that within the last ten years, the message about clinical documentation integrity has grown more to-the-point.  But, I know the reality involves a continuation of many, many doctors across the country not understanding why they are being asked to “beef up their documentation.”  How can you help with this effort?

Before anything else, it’s crucial to understand, appreciate, and empathize with the unavoidable fact that physicians, first-and-foremost, are most concerned with providing medical care to their patients.  I’m talking about face-to-face conversations, hands-on examinations, and complex rumination about the assessment and subsequent plan.  These actions which lead to actual stabilization or improvement of a patient’s medical condition are paramount to the physician.  RECORDING these events will always feel like busy-work at best and an utter waste of valuable and increasingly limited time, at worst.  When speaking with a provider for the first time about documentation issues, I make it clear we are on the same page about this and have no disagreement.

My next introductory point to providers involves the hard truth of the times they are practicing in.  “The business of medicine” is no longer something physicians can avoid.  Period.  While in years and decades past, those in the white coats could leave things like hospital and patient finances to “the suits,” those days are gone.  Like with any business, non-profit or not, if there isn’t enough money coming in to pay for the services provided, the services can’t be provided.  Since all billing and subsequent reimbursement is based on what providers include in the medical record, there is no getting around physicians having a great deal of responsibility for the financial health of their clinics, hospitals, and health systems.  Make no mistake, providers HATE this connection.  Many, if not most, believe provider documentation should solely remain as communication between the care team members and not be relied upon for creation of the bill for services.  Especially in the evolving world of artificial intelligence and electronic health records, there is a strong belief that there must be other ways to create an accurate bill without getting the providers into the fray.  Unfortunately, at the current time, there is not.  There is no wiggle room, here.

All physicians believe they provide the best care possible to their patients, but the death of paternalistic medicine brings the need to track and demonstrate truth in outcomes.  It would be ridiculous to bunch stats for the Major League Baseball team based on the North side of Chicago in with those for the Olentangy Little League travel team in Ohio simply because both are named the “Cubs.”  Likewise, not all “asthma exacerbation” is the same and expected to follow the same treatment and recovery path.  If the subtleties of asthma type are not elucidated in the record, you’re going to have the equivalent of Wrigleyville players’ reported performance on SportsCenter leading to 75% pay cuts for each and every Cubbie.

Physicians have long referred to patients as “theirs.”  “One of my patients really turned the corner and I’m so happy I can discharge him before Halloween,” is for certain a sentence I have uttered in my clinical past.  We are personally invested in the care of our patients but this mindset must expand beyond the patient themselves and beyond the day-to-day plan.  Make sure your providers know that providing the best care means keeping that care available in the area.  Just 20 years ago, the threat of the local hospital closing was not on the mind of many in healthcare.  Hospitals were a staple entity, a pillar of their communities which were possibly a presence for 100 years and expected to stick around for at least 100 years more.  Now, dozens of hospitals close a year and even more reduce or eliminate specific services entirely due to lack of funds.  Like it or not, justified or not, these funds are dependent on provider documentation in multiple ways. 

Physician notes no longer simply serve as communication between medical team members.  They are the very basis of ensuring patients receive safe, quality, effective healthcare and the foundation of reimbursement to the clinics, hospitals, and other facilities which allow patients to receive this care.  Is this a heavy lift?  Absolutely.  Should we reconsider daily provider patient loads to allow sufficient time for this critical responsibility to be accomplished well?  Something to consider….

About the Author

Juliet B. Ugarte Hopkins, MD is President of the American College of Physician Advisors, founder and CEO of Velvet Hammer Physician Advising LLC, and a member of the consulting team for Phoenix Medical Management, Inc. Dr. Ugarte Hopkins practiced as a pediatric hospitalist for a decade in Illinois, then developed the physician advisor role for case management, utilization, and clinical documentation at a three-hospital health system in Wisconsin. She was the first physician board member for the Wisconsin chapter of the American Case Management Association (ACMA), is a member of the RACmonitor editorial board, and is an author and national speaker.

Contact the Author

jugartehopkins@gmail.com