Guest post: Making progress with a progress note
By Karin Killenberger, BSN, RN, CCDS
I enjoy mysteries, puzzles, untangling that errant skein of yarn on occasion. But when I’m working, I’d like to leave mysteries and puzzles out of the equation.
Recently, I spent the better part of an hour combing through one history and physical (H&P) and one progress note. It seemed like it made sense, right up until it didn’t. The physician writing the notes had pulled in problems that had been treated in the past, but made it all seem like it was part of the current episode of care. I am glad I was being my usual methodical self, making mental notes, looking at dates.
Why was he documenting that in 2013 the patient was admitted for pseudomonas pneumonia with acute respiratory failure when on this admission the patient had acute-on-chronic renal failure, and new onset hepatic failure?
Why was he documenting the acute renal failure, which was not apparent according to lab results?
If you know, please contact me!
I really would like to understand what has happened to progress notes since the advent of the EHR. I thought they would be legible. Check, they are.
I thought they would be complete. They are going way beyond complete.
I work with EPIC, which allows the doctors to pull in every single lab result since birth, it seems. And every surgery since before the advent of anesthesia, every medication ever prescribed, and so on, and so on. You get the picture.
What do we do about this problem? How can we get the urologist to stop copying and pasting the cardiologist’s note? The real question is how we make the notes shorter and more concise. Some doctors never update their note from admission to discharge: the same note is copied and pasted over and over.
I wish I was kidding when I told you that I recently had a chart for a patient who had been an inpatient for 12 days and had this in his note: “Awaiting bed assignment: Will consult surgery for immediate OR” on the day of discharge. He’d had his bowel surgery the day of admission, but the physician never updated what he cut and pasted.
There are days I curse the EHR gods for giving doctors cut and paste capabilities. The only way to fix this problem (aside from getting with your IT guys on the hush-hush and having them inactivate cut and paste) is physician education. And I mean intensive education, because so many of them think they are doing an improved job of charting using the latest and greatest technology. But, the notes are overkill, swollen with not-so-useful information.
We need to educate the doctors one-on-one, in groups, at section meetings, in the elevator, in the parking lot, but we really need to educate them on just what a confusing mess their notes have become. I shudder to think what a court of law would have made out my confusing H&P and progress note. If those documents were all the court had to go by, I do not believe the lawyers would have it sorted out within an hour like I did.
We need to show our doctors a great H&P as an example and tell them, “This is how it’s done.” I know that some doctors are confused by the EHR, or even intimidated by it. Perhaps hospitals need to do a better job training physicians in using the technology, but it’s up to us to help them use it if they need the help. We are the ones in the record, seeing what has and has not been documented. We are the ones who can make them see how confusing their notes appear. We are the ones who can spend time lining up all the facts, the lab results, the radiology results, the consults, operative notes, etc. They are in that record once a day, and are trying to hurry up to get that done.
I know I need some help figuring out the mystery of convoluted notes so that they make some sense, but sometimes they still don’t tell the whole story. And I like to think our physicians would appreciate that help as well. Thank goodness we do have our shining stars, whose documentation serves as an example of a better note. Progress notes can be great again, I’m sure.
We just have so much job security; I don’t know if I’ll ever be able to retire! Educate those doctors, my CDI friends! We will all thank you for it in the end.
Editor’s note: Killenberger is a remote CDI specialist at Harmony Healthcare based in Howell, Michigan. Contact her at firstname.lastname@example.org. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.