Decades into caring for patients as an internist, I still worry about my progress notes.
I imagine Larry Weed, at rounds with us during my residency, pointing out my failure to write a decent problem-oriented note, that I did not clearly document the diagnoses I was considering, or that I was ordering superfluous tests or doing things outside the context of the overall goals for that patient. The creator of the Problem-Oriented Medical Record, Weed designed a version of the medical record the way a scientist would keep a lab notebook with an emphasis on principles such as reliable data collection, accuracy, clarity, thoroughness, and organization. Thus, the Problem List, organized elements of care (ie, subjective, objective, assessment, and plans [SOAP]).
Weed reasoned that forcing oneself to identify problems only to the level one understood them (eg, dyspnea rather than chronic obstructive pulmonary disease or heart failure) helped keep a doctor’s mind open to other possibilities. Dyspnea is, after all, complex. (Could the dyspnea be interstitial or restrictive lung disease? Could it be deconditioning? Is the patient anemic?) Writing plans so as to approach diagnoses by taking time to consider the differential diagnosis, monitor medication side effects, and order medicines in a logical and orderly manner, would not only improve patient care but would, Weed believed, also help doctors understand the nature of their patients’ diseases more completely. He thought, and further taught, that the medical record should guide and teach. And that if it was done well, it could be audited to determine if the care was thorough, reliable, analytically sound, and carried out in an efficient manner.
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Weed, an emeritus Professor of Medicine at the University of Vermont, died in 2017. He was a force in medicine and fundamentally changed how the modern medical profession writes notes and maintains medical records. His own electronic medical record (EMR), titled PROMIS, which he helped create in the 1970s, was problem oriented, and the crucial elements of his system exist in nearly all EMRs in the world today.
What Weed probably had not conceived, though, was the morphing of the record into a billing instrument that forced one to add elements of documentation that are irrelevant to a patient’s care. An auditor met with me a few years ago when we were being trained to bill “properly.” Reviewing a progress note I had written on an episodic patient, she suggested that in the future I consider including pupils equally round and reactive to light and accommodation (PERRLA) in my documentation because it added elements of the physical examination needed for a Level-4 outpatient visit.
Even more concerning is that now it has become difficult to believe that everything documented in medical records was actually done. When you read in a chart that “A 12-point review of systems was entirely negative,” do you know what was asked of the patient? When you read records with long and detailed templated reviews of systems and physical examinations, do you really trust them?
Copying and pasting are ubiquitous now (Crtl+Alt+C, Ctrl+Alt+V, repeat). But when you copy and paste in information, have you reviewed all the data? Do you know they are accurate? Are they relevant to the problems being addressed? As Alpert points out, EMR notes have become an “exhaustive compendium” often of unnecessary information copied and pasted into the note.
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And, as Gawande wrote recently in the New Yorker, quoting Dr. Susan Sadoughi, a busy internist in an academic medical practice, the Problem List itself “has become utterly useless” because of the tendency of multiple caregivers often using it to enhance billing. “They’re long, they’re deficient, they’re redundant.”3
- Gawande A.
Annals of medicine: Why doctors hate their computers.
https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers
Date accessed: March 28, 2019
Of course, even as the medical profession comes to terms with the shortcomings and potential pitfalls of EMRs,
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no one imagines abandoning them. EMRs have obviously brought great improvements. Data now appear at our fingertips, organized and comprehensive. Charts are no longer missing, incomplete, illegible, or misassembled, and medication errors are far less likely to occur.The EMR itself is not really the problem. Rather it is the coopting of the EMR for payers’ purposes. As long as the medical record serves as a billing tool first, the incentives to eliminate illogical, excessive, and inaccurate documentation will fail.
The medical profession must preserve the integrity of the medical record. Efforts to this end are already underway. For example Moser et al4 propose teaching students high-value and cost-conscious care with a modification of the traditional SOAP note by including consideration of value, or SOAP-V. Billing can be simplified as well so as to eliminate “extraneous and irrelevant information.”
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For example, Lasker and Marquis proposed a simple metrics-based billing method based on time spent and intensity of the visit.5
Ultimately though, we have to change incentives and separate medical record documentation from billing. And, we must never game the record to up-code billing.As Weed so eloquently put it, “We’re really not taking care of records; we’re taking care of people. . . . This record cannot be separated from the caring of that patient. . . . This is the practice of medicine.”
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We should strive to remember that. What is badly needed is a return to the principles he stood for—accuracy, clarity, thoroughness, and organization—principles that make us not better billers and not just better record keepers but better doctors.- Weed L.L.
Larry Weed’s 1971 Internal Medicine Grand Rounds.
https://www.youtube.com/watch?v=qMsPXSMTpFI
Date accessed: March 28, 2019
The medical record, if done well, should guide and teach and, most importantly, improve the care of the patient.
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That is after all, what its main purpose must be. Weed understood that the medical record is not only a learning and teaching tool, but it is the best representation of the care a patient is receiving. This, at the end of the day, is why I worry about my progress notes.References
- Medical records that guide and teach.N Engl J Med. 1968; 278 (652-657): 593-600
- The electronic medical record: Beauty and the Beast.Am J Med. 2019; 134: 393-394https://doi.org/10.1016/j.amjmed.2018.12.004
- Annals of medicine: Why doctors hate their computers.(Available at:)https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computersDate accessed: March 28, 2019
- SOAP to SOAP-V. A new paradigm for teaching students high value care.Am J Med. 2017; 30: 1331-1336
- The intensity of physicians’ work in patient visits-implications for the coding of patient evaluation and management services.N Engl J Med. 1999; 34: 337-341
- Larry Weed’s 1971 Internal Medicine Grand Rounds.(Available at:)https://www.youtube.com/watch?v=qMsPXSMTpFIDate accessed: March 28, 2019
Article info
Publication history
Published online: April 30, 2019
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Funding: None.
Conflicts of Interest: None.
Authorship: The author is solely responsible for the content of this manuscript.
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© 2019 Published by Elsevier Inc.
