I appreciate getting notes from specialists. Really. It’s great to be kept in the loop with patients’ care, especially when other doctors are using EMRs that directly fax me notes the same day as the visit. Sometimes, though, things can get a little out of control.
I’ve ranted before about offices that use templated EMRs to generate documentation of things they never actually did. Today I received the following letter:
Reason for the appointment:
1. Abdominal pain
2. Post colonoscopy with biopsy
History of present illness:
1. Abdominal pain: he failed to show up for this appointment
Current medications:
[med]
[med]
[med]
Past medical history:
[problem]
[problem]
[problem]
EGD 2008 negative, EGD 2011 negative, colonoscopy 2005 normal
2010 Chest CT with 3 mm lung nodule, low risk
Surgical history:
Appendectomy age 24
Family history:
Non-contributory
Social history:
Tobacco: non-smoker
Machinist, married, no children
Allergies:
PCN
Hospitalizations/Major diagnostic procedures:
Denies
Assessments:
1. [problem]: appropriate ICD-9 code for [problem]
2. [problem]: appropriate ICD-9 code for [problem]
NO SHOW
Plan:
1. Other
Electronically signed by I.M.Schmuck MD
Sign off status: Completed
That’s right. If you read that carefully, you will see that this entire note (which satisfies documentation guidelines for the history for a level 4 office visit) was generated FOR A PATIENT WHO WAS NEVER SEEN. Silly me. I always thought documenting a history implied that you had actually spoken to the patient. Maybe he’s in the hospital with a heart attack. Maybe he is now allergic to sulfa. Maybe he’s newly divorced and has taken up smoking again.
This document blows my mind. It is Exhibit A in how not to use an EMR. I have nothing against templates, and in fact have come to use them on a daily basis. Then again, I only use them to avoid repetitive typing of short phrases, not entire documents. Come on, people! This is the sort of crap that lets patients and pundits ridicule us so mercilessly.
If nothing else, I also have surprisingly little sympathy for doctors who complain about paperwork when they turn around and generate a 2-page note for a No Show.
Geez!
Dinosaur MD (aka, Lucy E. Hornstein, MD) is a solo-practitioner in Family Medicine. She is also a book author (Declarations of a Dinosaur) and posts frequently at her blog, Musings of a Dinosaur, where this post first appeared.
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