{"id":568555,"date":"2010-05-18T11:36:27","date_gmt":"2010-05-18T15:36:27","guid":{"rendered":"http:\/\/blogs.jwatch.org\/hiv-id-observations\/?p=937"},"modified":"2010-05-18T11:36:27","modified_gmt":"2010-05-18T15:36:27","slug":"electronic-medical-records-and-long-id%c2%a0notes","status":"publish","type":"post","link":"https:\/\/mereja.media\/index\/568555","title":{"rendered":"Electronic Medical Records and (LONG) ID\u00a0Notes"},"content":{"rendered":"

\"cat-and-dog2\"<\/p>\n

When it comes to writing consult notes, it often seems as if we ID specialists have a blatant form of obsessive-compulsive disorder. Every detail is fair game — travel history, dietary habits, all sorts of seemingly trivial exposures, and of course microbiologic data stretching back to the\u00a0Cretaceous period<\/a>.<\/p>\n

I’ll never forget receiving sign-out from the graduating first-year ID fellow when I started my fellowship. \u00a0It included a photocopy of a consult note she had written the day before on a woman with fever after gallbladder surgery.<\/p>\n

In five pages of meticulously-detailed prose, there was this memorable item from the Social History:<\/p>\n

\n

Two pets at home: \u00a0a dog (Rusty) and cat (Cleo); both are healthy.<\/p>\n<\/blockquote>\n

Good news for Rusty and Cleo! \u00a0But what could this possibly have to do with post-operative fever after gall bladder surgery? \u00a0Even if you allow that perhaps she was suffering from some bizarre post-cholecystectomy zoonosis (if there is such a thing), why was it necessary to cite the pets’ names?<\/p>\n

Electronic medical records have, if anything, made matters even worse for the detail-obsessed. \u00a0The ability to cut and paste endless reams of data into a note is irresistible to most ID docs.<\/p>\n

It leads to a bizarre paradox where the more information in the note, often the less useful it is — a phenomenon expertly\u00a0dissected\u00a0over here<\/a> on the always-interesting KevinMD blog. \u00a0Says guest writer Jaan Sidorov:<\/p>\n

\n

[A doctor] had received a copy of a lengthy consultant-physician\u2019s documentation involving one of his patients and was astonished by the blob of past data, prior notes, test results, excerpts, quotes, interpretations and correspondence that had been replicated word-for-word in the course of \u201cseeing\u201d his patient. The terse portions describing what the patient actually said, what the consulting doctor actually examined and what the diagnosis and plan were were\u00a0inconspicuously\u00a0buried toward the end of the EHR document.<\/p>\n<\/blockquote>\n

And you know what’s most maddening? \u00a0Under the current “guidelines” for coding and billing, there are true incentives — both financial and regulatory — to write this kind of text-heavy note, one heavily infused with templates and boilerplate language. \u00a0The more complexity the better!<\/p>\n

Here’s a proposal: \u00a0the goal of a consult note should be concise documentation of what you think, and why, then what you’re recommending, and why.<\/p>\n

I’m sure Rusty and Cleo would agree.<\/p>\n

<\/p>\n","protected":false},"excerpt":{"rendered":"

When it comes to writing consult notes, it often seems as if we ID specialists have a blatant form of obsessive-compulsive disorder. Every detail is fair game — travel history, dietary habits, all sorts of seemingly trivial exposures, and of course microbiologic data stretching back to the\u00a0Cretaceous period. I’ll never forget receiving sign-out from the […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[7],"tags":[],"class_list":["post-568555","post","type-post","status-publish","format-standard","hentry","category-news"],"_links":{"self":[{"href":"https:\/\/mereja.media\/index\/wp-json\/wp\/v2\/posts\/568555","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/mereja.media\/index\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/mereja.media\/index\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/mereja.media\/index\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/mereja.media\/index\/wp-json\/wp\/v2\/comments?post=568555"}],"version-history":[{"count":0,"href":"https:\/\/mereja.media\/index\/wp-json\/wp\/v2\/posts\/568555\/revisions"}],"wp:attachment":[{"href":"https:\/\/mereja.media\/index\/wp-json\/wp\/v2\/media?parent=568555"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/mereja.media\/index\/wp-json\/wp\/v2\/categories?post=568555"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/mereja.media\/index\/wp-json\/wp\/v2\/tags?post=568555"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}