Sunday, October 22, 2017

The Curse of Medical Records Documentation

Let me post a question that neither I nor readers can answer.
How much of what I do during the course of a day directly benefits patients?

Perhaps, I don’t want to really know as I would be dismayed at how much of my effort benefits no one. Ask a nurse who works on a hospital ward, how much of his or her effort is directly applied to patient care.  I would recommend that you have a double dose of antacid in hand – one dose for you and the other for the nurse. 

Just today, I was gently reproved by a hospital physician administrator for a lapse in one of my recent progress notes, which I write after seeing every hospital patient I consult on.  Which of the following transgressions do you think I was cited for?  Only one answer is correct.
  • I did not perform an adequate physical examination
  • I failed to address the results of an abnormal CAT scan
  • I neglected to write the time of day along with the date of the note.
  • I did not discuss the case with the patient’s family.
Just last week at our medical staff meeting, all physicians were told of the requirement to record the exact time, as well as the date, of our hospital visits.   This requirement, which is not new, is not to improve patient care.  It is a requirement imposed by the Joint Commission, which certifies that a hospital is complying with all rules and regulations.   I would like my readers to know that in over a quarter of a century of hospital practice, the visit times were recorded in 1-2% of all hospital notes of all physicians.  No physician has felt that the lack of recorded visit times negatively affected patient care.   Writing down the time may seem to readers to be just a minor irritant which takes only a few seconds.  It is, however, a symptom of documentation requirements that have run amok.

When the Joint Commission visits a hospital, the entire medical and administrative staff are on edge.  Why?  Because there are hundreds of requirements of dubious value that will be assessed  I support the Commission’s mission and recognize that many of the requirements are completely valid.  We want clean operating rooms, safe parking lots and a culture of respecting patients’ privacy.  But, trust me, many of the mandates from them can be trivial or absurd.

Colonoscopy Wildfire!

As an example, in our ambulatory surgery center where we do colonoscopies, we are required by the government to declare before every procedure if the patient is facing a fire risk.  Please do not ask me to explain this, as I am incapable.  Apparently, because we administer oxygen and use cautery, there is a flammability risk.

I want to reassure my current and future patients that to date our endoscopy center has been a flame free zone.  Moreover, the only instance where a firefighter was in our office was when he was getting a colonoscopy performed. 

The public would be shocked and outraged to learn how much of our time is spent racing on the hamster wheel, a difficult and timewasting exercise that yields no progress. 


  1. The time requirement is most likely from a medico legal incident in which a lawyer was building his case about giving a medication., Nurse notes and pharma have time desiignated when doses are given.

  2. Gary, thanks for the comment. Of course, you are correct that the requirement to document the time of the visit has more to do with creating a documentary record than in helping living, breathing patients. This is but a grain of sand on the beach of absurd documenation requirements. If you think I am exaggerating, ask any practicing MD or a hospital nurse. MK