Evolutionary Timeline of Medical Documentation

Posted on June 5, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’ve been kicking up some dust over on EMR and HIPAA about the awful EHR documentation that most EHR vendors produce (Full Disclosure: It’s not really the EHR vendors fault, but billing and other regulations). In response to my post, Peter Elias provided a great look at the history of medical documentation and how we got so far off track when it comes to using documentation as a clinical tool. Here’s his comment:

Evolutionary time-line…
In the earliest days it was sparse/terse and mostly for the benefit of the clinician:

1. Document the decision and treatment. (Otitis media – amoxicillin.)
2. Document the decision, supporting evidence, and treatment. (Bulging red R TM, OM, amox.)
3. Then it became necessary to document why other decisions and treatments were not elected.
4. The SOAP note and problem oriented recording developed to encourage tracking problems over time. Still a clinical approach.
5. The medical record slowly became a legal document. If you didn’t say you examined the calf and found no evidence of DVT, it meant you hadn’t done it and were liable.
6. The medicolegal record slowly became a billing record. In order to prove how hard you worked, you needed to document two from column A, three from column B, level 37 decision making, an explicit statement of risk. This required documenting lots of negative detail. ‘Pertinent negative’ in a ROS became a laundry list of clinically irrelevant but coding-dependent negatives.
7. Add meaningful use and other audit requirements, and there is another layer of information that must be acquired and recorded.

In all this process, sadly, the note stopped being primarily a clinical tool. I fantasize about a system that allows recording of all that clinically unnecessary flotsam and jetsam, but does not require including it in a clinical note. It goes into the database and is accessible for those who want it when they want it, but it doesn’t get between me and my patients.

Reading Peter’s comments made me wonder if we’re going to start having two types of notes. A clinical note and a billing note. That’s sad to consider that EHR vendors would spend their time coding their applications around the challenge of quality documentation.