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Expediting medical documentation


Let’s begin our recovery of medical practice by discussing alternative ways of documenting office visits.

When the editors at Contemporary Pediatrics invited me to launch this section in 2012, I had no idea how much fun I would have writing it, and that our readers would actually find the topics interesting. Like most of you, I work in a clinic. I enjoy treating my patients, and there is not a day that goes by that I need to navigate obstacles imposed by insurance companies, government reforms, and my electronic health record (EHR). If there were to be a theme for this year’s Peds v2.0, it would be “taking back the practice of pediatrics” for ourselves and our patients. Yes, there will be lots of tech articles this year because this leopard will never change his digital spots. However, let’s begin our recovery of medical practice by discussing alternative ways of documenting office visits.

More: Meaningful use 2? Just say no

When I conducted my last tech workshop at the American Academy of Pediatrics National Conference and Exposition in October last year (see “Best tech for pediatrics 2015,” Contemporary Pediatrics, December 2015), pediatricians told me that their EHRs were too hard to use, with the majority of attendees reporting that they are unable to complete their office notes during their regular hours. Many, if not most, were frequently taking at least an hour’s work home with them. This is no way to care for patients or ensure a quality life for medical providers!

Our current documentation system . . .

. . . is designed to justify the level of coding for insurance company reimbursement rather than facilitating documentation of the office visit. The purpose of the office note should be to convey our clinical impression of the patient’s medical problems and communicate our plan for treatment and further evaluation to those who will read our note. The EHR note ensures continuity of care for our patients.

If you read the Peds v2.0 article “Level 4 office-visit coding” from February 2013, you know that coding office visits are based on the “medical decision making” involved, the nature of the presenting problem, and the number of problems addressed at the visit. Unless you assign a time designation with your note, to justify a 99214 visit you must include numerous elements in your note to ensure payment as a level 4 visit. Thus, a level 4 history includes at least 4 history of present illness (HPI) elements; at least 1 item from the past medical history (a medication list or allergy list qualifies), social history, or family history; and at least a 2-system review of systems (ROS). The level 4 physical exam requires examination of 5 to 7 systems, including the patient’s vital signs.

As every provider knows, when a note is reviewed we glance at the previous HPI, but our focus is on the assessment and plan for ongoing medical problems. To begin “taking back the practice of medicine,” we need to accomplish 2 goals. First, we need to convince insurance companies and the government that there are better, alternative ways to compensate physicians. Second, we need a more meaningful way to document medical encounters. 

Rethinking physician compensation

Compensation of primary physicians is currently based on the notes associated with the office visit we generate when we care for patients. For procedure-based visits, insurance companies pay providers according to a fixed schedule for the procedure performed. In contrast, primary care visit payment is based on either the time spent at the visit and the amount of time counseling the patient or the medical decision making involved and the requisite number of elements needed to justify the level billed (addressed above). At the present time, “time stamping” our visits, is the only way to avoid writing lengthy notes in our EHRs. In the interest of patient care and preserving the sanity of medical providers, we should avoid level 4 coding based on medical decision making. It just preserves an unnecessary “kitchen-sink” approach to medical documentation. Time stamping our notes just works (given our present system), and it encourages the generation of more practical, concise office notes that ensure continuity of patient care.

Related: Communicating in the high-tech office

I would welcome alternative ways to compensate physicians that would be based on complexity of diagnosis (pneumonia should warrant a higher compensation versus upper respiratory infection [URI]), number of diagnoses, and perhaps the amount of follow-up that needs to be performed to complete the evaluation of a patient’s condition. For example, if we order labs or x-rays, we will need to contact a patient with the results, which can lead to further testing or referrals. Visits associated with the ordering of tests should trigger a higher reimbursement than a visit just for conjunctivitis or URI. Another method to consider is to pay by the click. Using software “click counters,” I have determined that by the end of the day I have clicked anywhere from 1500 to 2000 buttons. If I click more buttons, I would like to be paid more. This payment method may accelerate the evolution of EHRs to the point where they are more intuitive and user friendly, and can expedite the production of quality notes.

Better medical documentation

Our current system of medical documentation is based on the Problem-Oriented Medical Record developed and promoted by Lawrence Weed, MD, in the late 1960s. It is a systematic way of documenting a patient visit that has traditionally been associated with the SOAP note system: S stands for subjective and includes the chief complaint, history of present illness, family and social history, and ROS. Objective includes the vital signs and results of the examination. Assessment includes your clinical impression and Plan includes your recommendations for treatment and further workup (Table 1).

The SOAP system is straightforward and has proved its utility over decades of use. However, EHRs are template driven, and, as discussed above, to safeguard our salaries most primary care notes are bloated-easily many times as long as they need to be. If you stick with time-stamped notes, you can shorten your history elements to only the pertinent elements; likewise the ROS, which can be 1-line versus 10 lines in most of our notes (ie, 10-system ROS significant for nonproductive cough for 3 days). Similarly, only the pertinent physical findings can be listed in the Objective section. The most valuable part of the note is the assessment and plan. We should strive to generate office notes that can be viewed on a computer screen without scrolling!

APSO notes: The upside-down medical note

Most physicians consider the SOAP note’s assessment and plan to be the most important part of a medical note. Several physicians associated with the University of Colorado launched a quality improvement initiative a few years ago, whose goal was to convert clinics associated with the medical center to APSO format, in which the Assessment and Plan appear at the beginning of a chart note, followed by the Subjective and Objective (Table 2). Surveys were conducted after conversion to the new format. Eighty-one percent of respondents reported that finding clinically relevant data was easier with APSO versus SOAP format, and 83% reported much faster browsing through EHR notes with APSO versus SOAP noted. Additionally, 75% preferred reading notes with the APSO format.1 I personally do not like the APSO format, and suggest that we consider highlighting the assessment and plan section of our notes in red, to draw the attention of the reader immediately to the most important area. Significant physical finds also can be similarly highlighted.

Other ways to expedite medical documentation

Prudent use of abbreviations leads to abbreviated notes. The Joint Commission has a short list of medical abbreviations that should not be used because they can lead to medical errors. However, most organizations have a list of commonly used abbreviations that are approved for use by their medical providers. These include acronyms such as: “hx” for “history,” “dx” for “diagnosis,” “fx” for “fracture,” “tx” for ‘treatment,” “rx” for “prescription,” etc. In practice, we tend to use many abbreviations that are easily understood in the context of the note, considering the specialty of the author. For general pediatricians, ASD usually means “autism spectrum disorder,” while for the pediatric cardiology, ASD usually means “atrial septal defect.” “F/u” is typically used for “follow-up,” and “w/” for “with” and “w/o” for “without.” To avoid confusion, I recommend inserting a brief legend at the top of a note indicating the meaning of acronyms that are included in the body of your note. This legend can be easily included in your templates. Therefore, “moc” is indicated in your legend to indicate “mother of child” and therefore won’t be confused with “Maintenance of Certification.”

Related: MOC in haiku

Some physicians have templates that include check boxes to expedite the listing of positive history, ROS, and physical exam findings. Some may find this expeditious.

In addition, as I have indicated in previous articles, learning to use Dragon Medical Dictate can expedite creation of your abbreviated notes, and macros can be used for navigating screens in your EHR. The software is very affordable and it takes little time to become proficient. In addition, if your EHR doesn’t include macros for quickly inserting phrases, consider purchasing software that runs in the background of your operating system and facilitates text insertion by typing a short macro. For Windows, consider the $25 Shortkeys software (www.shortkeys.com/) or the free Macro Keys software (www.newsoftwares.net/macro-keys/). If you use a Macintosh computer, the $36 Keyboard Maestro software (www.keyboardmaestro.com/main/) is a worthwhile purchase.

NEXT: Problem list-oriented notes


Problem list-oriented notes

If the purpose of concise notes is to ensure continuity of care, consider including the patient’s existing problem list in your existing note. This serves as a reminder to update the problem list at every patient encounter. It also encourages physicians to remember to ask about conditions that may not be related to the visit at hand. Patients seen for ear pain may have longstanding problems with asthma, ADHD, or constipation, and it is worthwhile to use this opportunity to remind patients to take their meds, refill medications, or make problems inactive.

Next: What's new in 'connected' devices?


I hope this article will encourage you to rethink how you generate your office notes. I believe it is our responsibility to reform medical practice, and there are ways to accomplish this that are more obvious and more easily accomplished than others. Please write to me at Andrew.schuman@ymail.com to share your thoughts.



1. Lin CT, McKenzie M, Pell J, Caplan L. Health care provider satisfaction with a new electronic progress note format: SOAP vs APSO format. JAMA Intern Med. 2013;173(2):160-162.

Dr Schuman, section editor for Peds v2.0, is adjunct assistant professor of pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, and editorial advisory board member of Contemporary Pediatrics. He has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.

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