Hey DOGE, do medical documentation next
As recent as 18 years ago, I was able to hand write a paragraph as my medical note to see a patient for a home health visit. It took me 5 minutes. It was concise, describing what I did to help the patient, and an assessment of what was wrong with them. I had the entire time to talk to the patient face to face, and help them get better.
HIPPA passed in 1996, and the Unaffordable Care Act passed in 2010.
Now, depending on the platform, there are about 15-30 screens to navigate to complete a visit note. Much of it has nothing to do with someone’s health.
Here’s an example of how bad things have gotten. Below is an assessment I would have written 18 years ago. I spelled out some common abbreviations;
Patient presents with a total knee replacement of the left knee, date of surgery 10/29/2007, antalgic gait pattern, moderate yet expected post op pain and edema in the left knee, decreased strength and ROM. Fair tolerance for range of motion. Pt requires continued improvements in strength, gait quality and range of motion to return to previous pain free function.
In the objective section we will list the specific numbers to make sure we make progress, and in case someone else sees this person, they know where we left off.
Fast forward to now. This is not uncommon for me to read this…(bold emphasis is mine).
The patient presents with the following impairments, activity limitations and/or participation restrictions: Total knee replacement. 1 or more (HIGH) elements from any of the above body structures and functions, activity limitations and/or participation restrictions were addressed in the evaluation.
Patient's clinical presentation is MODERATE
Clinical decision making complexity was MODERATE and involved both standardized and measurable assessments of the patient's functional outcomes.
The patient will benefit from skilled physical therapy to address the above impairments, activity limitations and participation restrictions.
Patient Reported Post Treatment Pain Rating: 3/10
Preferred PT Practice Patterns
Musculoskeletal Patterns: Impaired Joint Mobility, Motor Function, Muscle Performance, and ROM With Localized Inflammation.
That rhetoric involved checking off about 15 boxes, like a data monkey.
I bolded that phrase because those were the only words that meant anything. There is a lot of important information missing.
What’s all that other crap?
Liability, data collection, and deniability
Most of the rhetoric addresses liability. This is “Fall of Rome” type stuff. We are so overburdened by liability, we have to account for any and all stupid things that people may do, or blame others for.
The rumor in Europe is that if you ski off a cliff and break your leg, that’s your fault. In Team America, you can sue the ski area for not holding your hand the entire day.
Second is data collection. The government needs to assign you a number, and track many parameters to manage the mess.
Third is insurance deniability, both private and public. “We are going to make documentation so pervasive, mind numbing, and arbitrary, we will find a way to deny your rhetoric, somewhere…”
All of the extra rhetoric that’s required, decreases safety. We might miss some important trees in the forest.
It also increases the overhead cost of healthcare.
Are you more captured by the medical and pharmaceutical pipeline by checking off more boxes?
yes.
Are we healthier with all the extra documentation?
no.
You have to CYA. It’s the dang lawyers😐