SGIM Forum

Medical Education: Part I

The New World of Outpatient Charting: A Threat or an Opportunity for Patients and Clinicians?

Relaxation of documentation requirements can be transformative for the busy clinician, inundated by electronic communications within the patient portal, prior authorizations, forms completion, and medication refills—piled on top of the increasing show rates that have occurred with increased telehealth usage. But there is yet another, arguably more important, reason why changes to documentation requirements may prove beneficial: they allow us to document at the level of the patient, who now has same-day access to our clinical thinking and medical decision-making via our notes.

The new documentation requirements from the Centers for Medicare and Medicaid Services for office visits offer internists an extraordinary opportunity to address the form and content of our notes. With the elimination of all stipulations for specific historical elements, Medicare allows us to set a new direction for communication and documentation within health care. At the same time, the 21st Century Cures Act and the OpenNotes movement (opennotes.org) present us with a unique opportunity to organize medical documentation in patient-centered ways, with renewed focus on empowering patients with access to their own health care.

Are patients, caregivers, and physicians interested? YES! A large-scale survey of patients using OpenNotes across multiple institutions revealed patients think note reading is important for their health.1 Another study of clinicians across three large healthcare systems revealed that 74% viewed note sharing as a positive and valuable way to engage and empower patients in their own medical care.2

Here, we aim to highlight new methods of documentation that (1) uncouple “quantity of information” from the complexity of medical decision-making, resulting in more focused, relevant notes and (2) offer commentary in ways that meet patients’ perceptions, expectations, and understanding of their medical illness(es) through open notes.

Framing Documentation around Medical Complexity

The outpatient evaluation and management codes (E/M) for new patients (99202-5) and established patients (99212-5) have been redefined. Service code selection can be made on either the time spent in care or the complexity of medical decision-making (MDM). In addition, time-based codes now include total time spent on patient care on the day of service, including same-day pre-visit review, face-to-face time, visit note preparation and completion, and any other communication related to a patient seen that day. When billing by complexity, now unencumbered by the inclusion of history and physical elements, how do you design the best note to meet medical complexity?

Begin with Problem-Oriented Charting. This includes diagnoses, undifferentiated complaints, findings, and test results. It may be best to reframe “problems” as patient characteristics and conditions. Importantly, this includes the social determinants of health. MDM is calibrated based on the number of problems addressed and the complexity or status of those problems. For this reason, problems should be designated as an acute exacerbation, a chronic condition requiring active management, or a stable chronic condition for which you plan to continue current management. Thus, the note should focus on the key information used to formulate the assessment and the plan, but there is no need to copy anything that is otherwise readily obtainable in the electronic medical record. Similarly, personal interpretation of data or a consultant’s report is more informative than copying and pasting a radiologist’s findings, which are already in the medical record.

Put the core content at the top. There is no reason that notes need to build to a conclusion and no need to separate the key history from the assessment and planning. These should all flow together in the charting under a given condition, problem, or characteristic.

Consider how the information will be used. Your notes both support your own continuity of care and summarize the information needed by the next clinical person, perhaps including any barriers to care, side effects to previous regimens, and patient preferences (e.g., a personal desire by the patient to avoid injections or to focus on lifestyle modification).

Framing Documentation for Open Notes

OpenNotes access is now a part of federal legislation. Our notes have to be simultaneously written for ourselves, our colleagues, and our patients. A recent article published in JGIM highlights the many ways our medical jargon can be jolting to patients, and suggests ways we might document differently for the lay community who can—and should—read our notes.3 Composing patient-friendly notes may require a different perspective than most of us were taught in training. What are some practical tips for documenting notes that better meet patient expectations?

  1. See your note from the patient’s perspective. Avoid jargon, acronyms, and pejorative language. Summarize in a way that is not intimidating. Cite the patient’s reason for the appointment as their primary concern rather than their chief complaint; name a problem as elevated BMI rather than morbid obesity. Additional considerations include referencing a person’s age rather than describing as elderly and to refer to disease states such as a person with sickle cell disease in place of a sickler.3 Replace dyspnea or “SOB” with difficulty breathing and cardiomyopathy with enlarged heart. Stating a patient “denies tobacco use” may sound accusatory; the objective comment that “the patient does not smoke tobacco” makes the same point.4
  2. Use a conversational tone. Write as if you are speaking to your patient. Consider a second-person perspective: “We discussed starting metformin this evening and checking the blood sugar each morning” instead of third person: “Metformin prescribed and instructed the patient to check qam fingersticks daily.”4
  3. Tell what happened. Use your note to reinforce the plan of care you discussed at the visit. If your note includes the possibility of cancer, your conversation with the patient should have already communicated this thought process.4
  4. Provide support, not judgment. For example, “The patient chose not to pursue treatment” instead of “The patient refused treatment” or was “non-compliant.”4
  5. Encourage your patients to read the notes. These notes can serve as a reminder of the visit and next steps as well as a tool for patients to share information with others on their care team. Ask the patient to view the note as a means to solidify mutual decision making between the primary care physician and patient. For example, write, “We discussed the side effects of this medication and ways in which it could be helpful,” or “We decided on starting at a half dose to lower the risk of side effects.”4

As physicians, we have become unwilling participants in the documentation burden, both creating and bemoaning “note bloat.” We have used note templates, cut and paste, etc. to meet unreasonable and anachronistic expectations. We hope that this summary guides SGIM members in preparing notes that are not only less burdensome and more useful for the next clinician, but most importantly, for the patient.

References

  1. Walker J, Leveille S, Bell S, et al. OpenNotes after 7 Years: Patient experiences with ongoing access to their clinicians’ outpatient visit notes. J Med Internet Res. 2019;21(5):e13876. Published May 6, 2019 [published correction appears in J Med Internet Res. 2020 Apr 30;22(4):e18639].

  2. DesRoches CM, Leveille S, Bell SK, et al. The views and experiences of clinicians sharing medical record notes with patients. JAMA Netw Open. 2020;3(3):e201753. Published March 2, 2020.

  3. Fernández L, Fossa A, Dong Z, et al. Words matter: What do patients find judgmental or offensive in outpatient notes? J Gen Intern Med. 2021 Feb 2. doi: 10.1007/s11606-020-06432-7. Epub ahead of print. PMID: 33528782.

  4. Klein JW, Jackson SL, Bell SK, et al. Your patient is now reading your note: Opportunities, problems, and prospects. Amer J Med. 2016;129(10): 1018-1021.


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