Detailed Documentation: Time Well Spent

Take this very common clinical documentation in EMR’s all across America: Assessment and plan: A 91-year-old man admitted from nursing home with UTI and confusion.

• Continue antibiotics
• IV fluids
• Monitor mental status
• Disposition: depends on course

And then the hospital medicine specialist or other provider proceeds to write an order that would make the patient as an inpatient. Such scenarios come to me as a physician advisor frequently. The question I am asked is: “Does this meet medical necessity for inpatient?” And, based on what I see in the above note, I say “no.” They will tell me: “You don’t understand, this is a very frail and very elderly man who has multiple comorbidities, and even though the numbers all looked normal in the chart, he was very ill appearing. I was very nervous about sending him back to the nursing home because I was afraid he was going to become septic at any moment. He has had multiple hospital admissions in the past with the same presenting symptoms, and he progressed to septic shock with multiorgan failure. That is why I think he warrants inpatient hospitalization.” I then reply: “I completely agree with you. If you had put that entire paragraph you just told me in the record, I would have no objection to agreeing with the inpatient order. Based on the previous documentation, however, I just could not agree with inpatient level of care.”

Being pulled in different directions

I get it. Clinicians nowadays are pulled in different directions. We need to be on top of a myriad of regulatory acronyms: MIPS, HCAPHS, RVUs, MACRA, etc. We in critical care have our own set of acronyms: MIPS, CLABSI, CAUTI, ABCDEF, VAC, iVAC, VAE, VAP, etc. Our days need to be 30 hours long if we want to finish everything and have some sort of decent work-life balance and not burn out in a few months, if not a few years. It is understandable that it may be quite hard to spend even more time writing long-winded notes in the medical record to justify our actions that are truly inherent to any reasonable clinician. Yet, taking that extra time to clearly outline medical necessity in the record is extremely important. This is because we have to realize that the notes we write in the medical record have two audiences. We think we are writing notes for other healthcare providers only. Yet, there is another audience: that of auditors, regulators, payers, and billers. What is inherent to us as clinicians, our first audience, may not necessarily be inherent to the second.

Document for your entire audience

For example, I may write this in a progress note on a patient in the ICU on a mechanical ventilator: The patient did well on both spontaneous awakening and breathing trial and was successfully extubated. To me, it is quite clear that the patient is critically ill. The same likely goes for other healthcare provider colleagues. Based on my documentation, however, that may not be clear at all to a third party auditor. You see, in my mind, when I write “patient did well on both spontaneous awakening and breathing trial,” I am actually saying this: “We stopped all sedative and analgesic medicines, which placed the patient at risk for extreme agitation due to being awake on a ventilator. Thus, we had to closely monitor the patient to protect against further harm. Further, we placed the patient on a spontaneous breathing mode on the mechanical ventilator, which further places the patient at risk for recurrent respiratory failure. Thus, we had to monitor the patient’s respiratory status closely. Once we were satisfied that the patient did well, we proceeded to extubate the patient. However, even after extubation, the patient was still at high risk for recurrent respiratory failure, and thus we continued to closely monitor the patient for several hours.”

The extra time is worthwhile

Writing the first sentence took me ten seconds. Writing the second paragraph took me dozens upon dozens of seconds. Add that over several patients every day, and we are talking about a significant amount of extra time. That extra time, however, is necessary because it is extremely important to clearly articulate in the record the vast degree of risk our patients face while being liberated from mechanical ventilation, for example, or presenting to the hospital from a nursing home with a UTI and confusion. What about note bloat? Doesn’t this long-winded paragraph just make an already long note even longer? Taking the extra time to clearly articulate risk and medical necessity is not adding useless information. It is helping everyone else see what we are seeing as a clinician at the bedside. No one can read our minds, and we cannot assume that everyone reading our documentation will understand what we are thinking. We have to clearly spell it out in black and white, and yes, it may take more time but it is time tremendously well spent.