Moving The Needle on Clinician Documentation

In January 2023, the Centers for Medicare and Medicaid Services (CMS) changed the billing and documentation rules, de-emphasizing the history and physical portions of the notes and emphasizing medical decision making. I hailed the changes.

No longer do I have to worry about being forced to document unnecessary things, such as a "review of systems," and I can focus on documenting what really matters: what I think is happening to the patient, and what I am doing about it. We need to take this opportunity to finally move the needle and raise our documentation to the level it should have been all along.

For example, in the past, it would not be uncommon for my consultation or progress note to look like this:

Assessment/Plan:

1. Septic shock
2. Urinary tract infection
3. Acute renal failure
4. Acute respiratory failure
5. Anemia
6. Leukocytosis

-- Continue full vent support

-- Continuing to titrate propofol and fentanyl

-- Continue antibiotics

-- Continue to monitor renal function with repeat serum studies

-- No blood transfusion needed. Repeat CBC in the AM

-- Monitor WBC count with repeat CBC in AM

While this note does give a sense of what is happening with the patient and what we are doing about it, it still does not give a full sense of how sick the patient is. Is the shock better? Is it worse? Does the patient still need vasopressors? How is the renal failure? Can the patient come off the ventilator? The note doesn't say.

Or, take this initial History and Physical assessment and plan:

Assessment/Plan:

1. Sepsis
2. Urinary tract infection
3. Altered mental status

-- Antibiotics

-- Monitor mental status

-- IV fluids

How sick is the patient? Does the patient even need to be hospitalized? Why are you wanting to admit this patient in the first place? If this note is a progress note, and the objective data are all OK, then why are you electing to keep the patient hospitalized? Why can't the patient be discharged? Again, the note doesn't say.

Now that I have been "freed" from the old regime, I am able to take my documentation to the next level:

Assessment:

Mr. Smith is critically ill with septic shock causing acute hypoxemic respiratory failure, acute renal failure, and acute metabolic encephalopathy. The source is likely pyelonephritis, which is demonstrated on CT abdomen/pelvis imaging, which I personally reviewed. He is requiring invasive mechanical ventilation and vasopressor support. The patient also is requiring continuous renal replacement therapy for the acute renal failure. All of these life-threatening conditions require ICU admission for management and close monitoring.

Review of the laboratory studies, which were ordered to assess the effect of the above conditions on various organ systems, also reveal the following: anemia (8.6 g/dL), elevated serum creatinine (4.2 g/dL), hyperkalemia (5.9 mmol/L), and leukocytosis (33.4). The anemia is chronic (and near her baseline), the leukocytosis is likely reactive, and the hyperkalemia is likely due to the acute renal failure.

Plan:

1. Continuing full support with mechanical ventilation, titrating FiO2 and PEEP to maintain adequate ventilation and oxygenation.
2. Continuing to titrate propofol and fentanyl to maintain the patient at target sedation and control pain while on mechanical ventilation.
3. Continuing empiric IV antibiotics, awaiting culture results
4. Continuing to also titrate norepinephrine to support mean arterial blood pressure
5. Continuing CRRT under the direction of Nephrology. The hyperkalemia should improve with CRRT, and we will monitor the hyperkalemia with repeat serum studies every six hours.
6. The hemoglobin is above transfusion threshold. Continuing to monitor the patient's anemia with repeat CBC in the AM.
7. Continuing to monitor the patient's leukocytosis with repeat CBC in the AM as well.

This note better tells the story of how sick the patient is and why he requires ICU admission. It demonstrates that I have reviewed the pertinent imaging and laboratory results, whereas before, simply pulling them into the progress note electronically does not mean I actually looked at them. This note tells you what I am doing about the various life-threatening conditions he has.

As another example, when we are admitting a patient to the hospital, we can document like this:

Assessment:

Ms. Johnson has sepsis from an acute urinary tract infection, meeting the following evidence based-criteria: she has acute metabolic encephalopathy (GCS 10), acute kidney injury (BUN 30, creatinine 2.8 mg/dL), and hypotension. The hypotension was likely due to intravascular volume depletion, and it has improved after volume resuscitation in the hospital emergency department. These conditions are life-threatening, and they place her at great risk for worsening organ failure, morbidity, and mortality. While she is encephalopathic, she is able to maintain an open airway.

I personally reviewed the CT abdomen/pelvis, which was ordered by the Emergency Medicine physician to assess the source of her infection, and to my interpretation, it shows no significant abnormality. Review of the laboratory studies, which were ordered to assess the effect of the above conditions on various organ systems, also reveal the following: anemia (10.8 g/dL), which is likely chronic; and leukocytosis (18.6), which is likely reactive.

Plan:

1. Given Ms. Johnson's age, underlying medical history, and co-morbid conditions, she is at very high risk for adverse outcome if she is treated at a lower level of care. Outpatient antibiotic therapy is not feasible. She needs close monitoring that can only be safely delivered at the inpatient level of care. Therefore, I am admitting her to the hospital for further treatment.
2. Continuing ceftriaxone 1 g IV daily for the UTI, awaiting the results of both blood and urine cultures.
3. Continuing LR infusion at 125 mL/hr, and we are monitoring the acute kidney injury with repeat serum studies in the morning.
4. Continuing to monitor her hemodynamic status closely. She does not need vasopressor therapy currently.
5. Continuing to monitor her mental and neurologic status with serial neurological assessments every four hours. Hopefully, with continued treatment, her encephalopathy will improve.
6. The hemoglobin is above transfusion threshold. Continuing to monitor the patient's anemia with repeat CBC in the AM.
7. Continuing to monitor the patient's leukocytosis with repeat CBC in the AM as well.

This note tells me how sick the patient is and why I have decided to admit her to the hospital. For progress notes after admission, the same is true: we can document clearly why the patient needs continued care in hospital and cannot be safely discharged.

Now, are these notes much more verbose? Absolutely. But, they allow anyone reading the note to understand what I am thinking about the patient's condition. While it may seem intuitive to me, a clinician, why I am admitting a patient to the hospital or the ICU, it may not be to any number of third parties (auditors, insurance companies, or even malpractice attorneys) who are also reviewing the record. Giving a full account, in narrative terms, of my assessment of the patient's condition will leave very little to intimation or speculation.

Will they take more time to document? Perhaps. But, that has not been my experience. I can document a very robust note in less than five minutes, especially with the dictation functionality present in almost all EMRs.

Well, one may ask, why didn't clinicians (especially doctors), including myself, always document like this? This is a great question, and I am sure that there are some clinicians who have been documenting like this all along. At the same time, the previous rules regime - with the onerous requirements for multiple elements of history, physical examination, and problem points for proper reimbursement - was not conducive to documenting a long narrative assessment. Especially with the advent of electronic medical records, the old rules provided an incentive to create a multipage note that said absolutely nothing. Now, the new rules allow such a narrative assessment to be acceptable. In fact, it encourages it.

Maybe it is because I am a writer that I am a huge fan of these new documentation rules. Yet, I feel "liberated" from having to follow senseless and useless rules for acceptable documentation under the old system, and I can finally tell the patient's story in my consultation and progress notes. In fact, I always put my "Assessment and Plan" part of my notes at the very top, so my colleagues do not have to scroll down to read it. Moreover, my notes have been cut by more than half, which is also a beautiful thing.

Clinician documentation is the most important part of the medical record. Everything about an individual hospital stay links back to it: the level of care of the hospital stay, the diagnoses upon which DRGs are based, continuation of care, among many other things. The better our documentation, the more robust it is, the less things are left to chance or speculation. The better our documentation, the less likely insurance companies can deny the level of care or even a specific DRG. The better our documentation, the easier it is for a physician advisor like me to defend the care that a physician colleague is delivering.

It is high time we move the needle on clinician documentation. It is high time we finally document like we should have been documenting all along.