A man is flying in a hot air balloon and realizes he is lost. He reduces height and spots a man down below. He lowers the balloon further and shouts, “Excuse me. Can you help me, I’m lost?”
The man below says, “Yes, you are in a hot air balloon hovering approximately 40 feet above this field.”
“You must be an expert at using an Electronic Medical Record,” says the balloonist.
“I am,” replies the man. “How did you know?”
“Well,” says the balloonist, “everything you have told me is technically correct but totally useless.”
I often think of this story when reading clinical notes in an Electronic Medical Record (EMR). The facts may be there but without a proper framework, reference point or context, the information may be difficult to use or interpret. When you are reviewing charts you need to be alert and recognize opportunities for improved documentation so that coders have sufficient context and clinical indicators to support the coding of a condition. While this blog entry is primarily geared toward clinicians, there are also valuable tips that can be used by Clinical Documentation Specialists to assist the clinicians in writing better notes.
Recently, I was reviewing the chart of a patient who had developed complications from an infection. The admitting note described the initial infection as a discrete lesion that was associated with signs of inflammation (localized heat, redness and swelling). The physical examination description included a normal blood pressure, no further description of the patient’s appearance or overall skin appearance, and did not document the patient’s mental status. The laboratory data showed an elevated white blood cell count and an elevated serum lactate.
At which point my internal alarm bells started to go off — something did not add up. An elevated serum lactate indicates that cells are not getting enough oxygen. Monitoring the levels of serum lactate may be helpful in diagnosing and treating conditions such as shock and trauma, but nothing in the notes on the chart indicated that there was concern about either condition. What was it about the patient’s presenting picture that led the clinician to order that blood test?
My guess is that the patient may already have been showing signs of shock. Blood pressures can sometimes be misleading and normal, even when blood flow to vital organs is starting to shut down. Some of the associated findings (more reliable than blood pressure alone) include a decrease in urine output (not yet apparent when the patient is first seen), altered mentation, and skin that is cool and clammy.
But the big lesson here is, don’t make me guess! If the admitting note had provided a more complete picture of the presenting findings, I would have had a clear context to interpret the blood test and the reasoning behind ordering it.
Here are some tips that you can offer your clinicians to improve the quality of their notes, not only helping them to communicate better with their colleagues, but also providing better documentation for coding and billing.
The pull-down menus and “smart notes,” or templates, that are pervasive in today’s EMR world can contribute significantly to the creation of a clinical note that is factually correct but not very helpful. Help your clinicians to learn that they should not let those tools get in the way of their ability to paint a complete picture and tell a meaningful story. They’ll practice better medicine, and their colleagues will be most grateful.
If you’d like more information, want to schedule a one-on-one demonstration, or just want to let us know what you think, please fill out the form below and we’ll contact you as soon as possible.
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