Electronic health records continue to be instituted within hospitals in order to more efficiently capture the documentation of the patient story. In a recent article “Clinical Documentation in the 21st Century” we hear the position of the ACP (American College of Physicians), "The clinical record should include the patient's story in as much detail as is required to retell the story." This short statement appears simple but leaves a lot of interpretation and unknown to the picture and can be a cause of Note Bloat.
As a recipient of the EHR (Electronic Health Record) for our work, Clinical Documentation Improvement/Integrity (CDI) specialists can all agree that they have solved one of the biggest issues in the old paper record – ability to read handwriting! The new progress notes in the EHR can be overwhelming to find the new and important information for the day when using a SOAP format of charting (Subjective, Objective, Assessment and Plan). So much of the Subjective and Objective today is pulled from other parts of the record (laboratory & radiology reports to name a couple) that if not structured by template policy can be extremely long (I once saw a 24 page Progress Note when printed to paper!). Thus many providers have gone to an APSO (Assessment, Plan, Subjective and Objective) format for EHR note writing. This only solves the issue of bringing the more immediate decision-making information to the top of the note, but does not address the core issue.
The story being told by the provider to other providers and the patient in the written format must be in such terminology as to allow the appropriate retelling to the insurance industry and quality surveillance entities out there, through what is termed the ICD-9 code set. The selection of the appropriate codes is guided by Coding Clinic (which is comprised of cooperative parties, none of which are physician-based) and coding guidelines. Both sets of "rules" can be interpreted differently depending on the interpreter.
ICD-10, which is slated to be implemented in October 2015, will only add to the complexity of the issue. The new code set will replace ICD-9, which is outdated and does not have codes to accurately reflect the specificity that is suggested to be in the record in order to tell the story. It is time that all parties involved come together to begin to agree on some standing provider documentation principles for the use of the EHR. These parties would include the patient first, providers, insurance industry, and the HIM industry.
The need to review your current electronic record policies as they pertain to clinical documentation templates, as well as audit your current records in order to see if you have a note bloat issue is imperative. The efficient use of your medical record system along with the accurate capture of the codes to reflect it can many times be achieved with the help of outside eyes. Email us at firstname.lastname@example.org for more information on our CDI services.