Fix our notes – our patients deserve meaningful notes

Stephen Martin and Chris Sinsky have a brilliant piece in the Lancet – The map is not the territory: medical records and 21st century practice. Unfortunately, you will have to download the piece or get a copy from the library. This concept echoes a common theme from this blog.  Here is a collection of posts that I have written over the past many years on the topic: The movement to improve patient notes We should require meaningful notes – attention CMS Progress notes – poor match between billing and medical information J’accuse – our notes are meaningless The degradation of physician’s notes This theme recurs over a 7 year period.  Our notes no longer reflect thinking; they no longer assist patient care; they do not communicate amongst other physicians. I want to be optimistic about the future, but fixing this problem never seems to develop any traction.  Every physician with whom I have discussed this problem agrees.  I can think of no other medical issue that really has 100% agreement among physicians. As the Lancet article documents very nicely, we have CMS to blame for this idiocy.  Seemingly, they do not care about patient care, rather they want a formula for payment.  Somehow we must dissociate payment from the form of our notes.  Patient care suffers because notes no longer convey information.
Source: DB's Medical Rants - Category: Internal Medicine Authors: Tags: Medical Rants Source Type: blogs