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Tell the Story in the Daily Progress Note

We need to stop thinking of it as copying and pasting, and have a paradigm shift to consider it copying and editing. 

Last week, Shannon DeConda bemoaned the fact that we have lost the story of the encounter. She postulated that the primary impetus for this in the electronic environment has been convenience.

I agree that convenience is compelling, but if providers are doing it right, I’m not even convinced that copying and pasting is convenient and time-saving. We need to stop thinking of it as copying and pasting, and have a paradigm shift to consider it copying and editing. If a provider plunks down a copied assessment and plan into today’s note, they should be reading it with a fine-toothed comb to make sure that it accurately reflects the encounter today. It is labor-intensive to edit.

Here are some tips:

  • I often see the entire history of present illness (HPI) paragraph copied into every daily progress note, and then the provider types out a few sentences about how the patient is doing today (i.e., the interval history). If the provider insists on this behavior, have them flip the sequence so that the new information is atop the note. Realistically, if I want to know what happened in the HPI, I can go to the admitting history and physical (H&P).
  • I personally hate the “Twelve Days of Christmas” assessment and plan (A&P) list. I don’t want to know what happened over the course of the last week; I want to know what is happening today, or at least, since the patient was last documented. If the provider is married to this format, have them bold new information so the reader can easily and quickly identify it. They will need to un-bold that information the next day and bold the novel entry again.
  • Have documenters mark conditions “resolved” to make it clear that they are no longer active, but that they should remain in the reader’s consciousness. It is important that a patient had acute hypoxic respiratory failure on admission, but it is misleading to bill it as a current problem if the patient is comfortable on room air today.
  • More is not always better. Concise, understandable, and actionable is better. Do providers like reading other people’s copying and pasting? If not, remind them that their copying and pasting is someone else’s “I hate reading other people’s copying and pasting.”
  • Differential diagnoses are good to let other caregivers know what the practitioner is thinking, but that section should be dynamic. If a diagnosis is ruled out, eliminate it from the list. If a definitive diagnosis has been determined, the differential diagnosis list has served its purpose and should be retired and removed.
  • Documentation should evolve. Has the organism been identified after the culture results return? If so, it should be incorporated into the assessment. Did they figure out the etiology of the sepsis with an uncertain source? Stop documenting “1. Sepsis of uncertain etiology; 2. UTI.”
  • Linkage, linkage, linkage. What caused the cellulitis, which caused the sepsis, which caused the various organ dysfunction?
  • The provider is being paid the big bucks to think, analyze, and synthesize. They should demonstrate that in their documentation. They should detail what they are basing their diagnosis on, but it does not necessarily have to appear every day. Explaining criteria for diagnosing severe protein-calorie malnutrition is crucial, once, at diagnosis; they do not need to repeat the BMI, muscle wasting, and weight loss every day. It would be appropriate to document the treatment daily as long as it is still accurate today.
  • Problem lists or A&Ps should not include every condition or surgery the patient has ever had. If it isn’t relevant to why they are here now, it shouldn’t be on the list. There is no extra credit for volume.
  • When temporal words are copied and pasted, they completely disrupt the integrity of the story. Did that happen yesterday? Or was it four days ago, and it has been copied and pasted without edit for three days?
  • The discharge summary should be a summary of the important events and a list of all the important diagnoses. A slipshod discharge summary can wreak havoc with the DRG and risk adjustment.

The providers need feedback. They don’t realize that anyone else reads their documentation or cares what they write. But we do. They won’t change their behavior unless they know they need to. Let them know – send them the link to this article!

Programming Note: Listen to Dr. Erica Remer when she co-hosts Talk Ten Tuesdays with Chuck Buck, Tuesdays at 10 a.m. Eastern.

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Erica E. Remer, MD, CCDS

Erica Remer, MD, FACEP, CCDS, has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

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