Page 10 - Volume 69 Number 2
P. 10

note a progress note; what a discharge summary needed to say; who the most important customers were of the information contained in the chart. Coherent narrative was of upmost importance. The chart needed to tell a story, and the story it told needed to make sense. You need to be able to read a chart and learn what is (or was) going on and why. What was the problem; what was going to be done about it? What actually happened, and why? What was the plan of treatment; what were the results? Treatments were to be recorded, the reasons for them explained; results of care documented without excuses, emotionalism, or value judgment. Conclusions were to be drawn only when there were facts recorded to support them.
There was something else: the chart had become a billing document. Payers, starting with Medicare, facing rapid increases in medical care costs, changed the way it paid for hospital care completely. Prospective payment or Diagnosis-Related Group-based reimbursement was instituted in the mid-1980’s to rein in Medicare spending. This called for yet more documentation. Hospital admissions now had to be justified. At the same time, new requirements had been promulgated for frequency of documentation and the type of content needed to support professional billing. Eventually in ambulatory care, insurers began to demand documentation that
patients were getting what they were paying for. If I wanted to be paid for a complex care consultation, now I had to prove it by means of complex care docu- mentation (and attest to it). Thus began the slide down the slippery slope of documentation whose chief purpose is to support billing. (I will return to this issue when we consider templated notes in Part II.)
The essential difference between a paper chart and an electronic medical record is that to make most entries in the former, pen is put to paper; in the latter, fingers are put to a keyboard, or visit details are dictated. In both forms, narrative is preserved. Once we got used to it,
and learned to type notes into the computer or dictate, CareWeb became an asset. It was particularly useful by being legible and enabling quick electronic retrieval of information, which had been becoming increasingly difficult as paper charts were becoming more volumi- nous and unmanageable.
But there was also a downside. One attribute of the paper medical record is that you had to be there, on the floor or in the room, with the patient and the nurses, to put something into it, because that was where the chart was. If you wrote a note, you had to have been there.
If you wrote the note correctly, you put in the date and time. Notes were entered consecutively on paper as would be done in a well-kept research notebook. Dictated notes likewise kept a clear, immutable record of dictation date and time (although you did not need to be there in person any more). The chronology of events was clear from the notes. Your handwriting and signature (even if barely legible) were proof of identity. Any note entered out of sequence was suspect.
Distributive computing and the new EHR have changed that. You have to be present (or at least attest to having been present) when care is delivered, but you no longer have to be there to record what happened. You are no longer faced with sheets of paper containing the notes of others. You can enter your note in isolation, in your office, at home, using your iPhone while at a conference. You are less likely to actually read the other entries in the chart, which it was hard to avoid doing when writing a note in
a paper chart. Notes are no longer necessarily entered or found in time-sequential order. Thus it has become harder when reading the chart to find out exactly what is going on. The ability to make entries into the chart without actually being anywhere near the patient has opened
a new pathway to fraudulent billing. That brings us to Part 11 of the saga.
10 Washtenaw County Medical Society BULLETIN

   8   9   10   11   12