Should Physicians Document Only for Other Physicians?

With the advent of ongoing audits for medical necessity and accurate coding, and an increase in denials by Recovery Auditors (RAs), Medicare Administrative Contractors (MACs), Commercial Payers, and others, proper documentation in the medical record has become more important than ever. And whose documentation is being scrutinized to ensure that the medical services being provided are reasonable and necessary? The answer: physicians.

For the last 17 years, the “1997 Documentation Guidelines for Evaluation and Management Services” has served as a benchmark for physician documentation. And yes, you read that correctly — there have not been any formal updates since 1997. When you think about it, RAs were not even around in 1997. The MACs were years away from forming, and commercial payers were not aggressively pursuing concurrent and retrograde audits to any degree.

Doctors typically document for other doctors. They do not document for coders, Utilization Management (UM) staff, or other reviewers. To put it into perspective, for every one physician that reads another physician’s History and Physical (H&P), there may be as many as 20 non-physicians who will read that same document.

Physician documentation has evolved over the years, but not always in a good way. There are a number of reasons why physician documentation has deteriorated, but the 2 primary factors for this are the emergence of the electronic health record (EHR) and the uneasy transition from a source-oriented record to a problem-oriented record.

Electronic Health Records — Friend or Foe?

In terms of physician documentation, the road to EHR adoption has been a bumpy one at best and has faced many challenges along the way:

• EHRs are typically designed by non-clinicians — basically, programmers who are not as familiar with how hospitals and clinicians actually function. These non-clinicians can be very sophisticated program writers capable of converting the older paper chart system into a technologically competent program. EHRs hold so much promise that, according to The New York Times, “the federal government is spending more than $22 billion to encourage hospitals and physicians to adopt electronic health records.”
• As the Times reports, “cutting and pasting” (C&P), commonly referred to as “copy forward,” may allow for “information to be quickly copied from one portion of a document to another, as well as reduce the time that a doctor spends inputting recurring patient data,” but it also leaves the window open to potential fraud. In an effort to cut down on C&P abuse by physicians who are performing less work than they actually bill, the OIG plans to make the scrutiny of cloning a priority for the coming year, the Times said.
• The opportunity for physicians to include their own thoughts and comments within the EHR is limited, even non-existent in some situations. So much within the record is a template, a checkbox, etc.; however, it is essential for physicians to document their impressions, assessments and courses of action for the patient. Additional documentation on the patient presents problems to physicians who lack the typing skills or are under time restraints. However, there are programs available (i.e., scribes, voice recognition programs, etc.) to help with this issue, but, of course, everything comes with a price tag.

Transitioning to a Problem-Oriented Record

In the late 1960s, one of medicine’s revolutionary thinkers, Lawrence Weed, MD, developed the problem-oriented medical record (and deservedly became known as the “Father of POMR” in the process). The POMR is a disciplined approach for physicians to provide proper documentation in the medical record. Through POMR, Weed created the SOAP note (an acronym for “Subjective, Objective, Assessment, Plan”), which gave physicians a structured approach to gathering and evaluating the volumes of information contained in the medical record and provided them with an avenue to better communicate with each other.

In his classic presentation to Emory Medical Center in 1971, Weed stated “…The way you handle data determines the way you think,” and “The structure of the data determines the quality of the output.” Think of it as a phrase we commonly use: “Garbage in, garbage out.” If the input data is not good, the output will be of the same quality. Physicians handle multiple elements of data from variable sources at variable times and then process that data in order to produce quality output translated into treatment plans. This is usually represented in the Assessment/Plan section of the H&P.

Today, physicians have essentially abandoned the fundamentals of the SOAP approach to the more straight-forward, but not necessarily well-rounded “Problem List” approach. For this transition to be effective, physicians must be able to successfully address the following:

• The problem list was actually designed to help with treatment progress. In the EHR, the Assessment/Plan can be legitimately copied and pasted to the next day’s progress note, but must be modified to reflect the patient’s progress, solve a clinical problem, or develop a new one. Many times, the initial problem list is copied and pasted, unchanged, from one day to the next with no original thought or comment. This practice can present challenges for UM, coding, discharge planning, and others.
• The problem list may not adequately express the physician’s concerns for what is actually going on with the patient.
• The problem list may not connect the risks and acuity with which the patient presents.

As an example, the physician may note the following: peri-rectal abscess — presenting diagnosis with the following co-morbidities:

1. COPD
2. Atrial fibrillation on anticoagulants
3. Diabetes Mellitus
4. Hypertension

All of the problems are listed and the treatment of each of these problems may follow, but this process does not express the risk of potentially taking a patient who is anticoagulated to the OR, or a diabetic developing — or the risk of a diabetic developing – necrotizing fasciitis even while treatment is rendered. To a physician, these conclusions may be obvious (i.e., physicians document for other physicians). However, with this new audience of reviewers and coders are not allowed to draw conclusions unless stated by the physician.

The Power of the H&P

Arguably, the most important physician document in the medical record is the History and Physical. The H&P should be a stand-alone document, as it is the main evidence to support why the patient has come to the hospital and why they will be receiving the care provided. It is this explanation that provides the cornerstone of medical necessity for the level of care in which the services are provided. Going back to documentation basic principles, there are 11 elements that make up the H&P:

1. Chief Complaint (CC)
2. History of the Present Illness (HPI)
3. Past Medical/Surgical History (PMH)
4. Social History
5. Review of Systems (ROS)
6. Vital Signs (VS)
7. Physical Exam (PE)
8. Labs
9. EKG/X-rays/Tests
10. Assessment
11. Plan

Thus far, I have reviewed 267 charts throughout the United States, randomly chosen by hospitals for documentation reviews. The reviews were performed, looking for deficiencies and areas for improvement to adequately document the acuity with which a patient presents. Below are the cumulative results from a total of 267 charts reviewed nationally:

Element

# of Times Present

% Absent

CC

224

16.1%

HPI

2⁵6

4.1%

PMx

249

6.7%

SHx

245

8.2%

ROS

220

17.6%

VS

221

17.2%

PE

248

7.1%

Labs

170

36.3%

Xrays, EKG, Tests

171

36%

Assessment

227

15%

Plans

222

16.9

What stands out in this data is the frequency in which essential elements of a patient’s H&P are missing. Remember what Dr. Weed said more than 40 years ago: “The structure of the data determines the quality of the output.” And the output in this situation is in the Assessment and Plan.

Following the Code

Another new audience affected by documentation is Clinical Documentation Improvement (CDI), which can have significant impact on physician’s quality measures. Oftentimes, physicians may misinterpret the use of coding for hospital revenue and not fully understand its importance of documentation for better accuracy and specificity.

Better documentation can affect 2 quality measures: Severity of Illness (SOI) and Risk of Mortality (ROM). These measurements are rated from 1 to 4 with the higher the number, the greater the acuity. In regards to this measurement, for the physicians who say, “But my patients are sicker,” better documentation will help physicians to get credit for that acuity. This is exactly some of the data that is being used to reflect the quality of physicians and comparing them to their peers. It can be found in many places, such as “HealthGrades.com” and Medicare’s “Physician Compare.”

In Conclusion

There are many other audiences that physicians must document for other than their peers. Data is being collected based on this documentation, depicting the quality of physicians and comparing them to their peers. In the future, decisions for payment, employment, and patient satisfaction will play a very important role. We need to teach physicians to how to document for today’s standards, not those of 1997.

John D. Zelem, MD, FACS is Executive Medical Director, Client Relations & Education at Executive Health Resources, Newtown Square, PA.