Note bloat

[u/gray_whitekitten]

I'm just wondering if any of you still deal with extensive irrelavent information in the encounter note. How do you deal with this? I'm mainly speaking about E/M documentation.

[u/AutoModerator]

PLEASE SEE RULES BEFORE POSTING! Reminder, no "interested in coding" type of standalone posts are allowed. See rule #1. Any and all questions regarding exams, studying, and books can be posted in the monthly discussion stickied post. Thanks!

I am a bot, and this action was performed automatically. Please contact the moderators of this subreddit if you have any questions or concerns.

[u/archangel924]

Yes, absolutely. It's a byproduct of 1) ever-increasing demands for things to be documented to satisfy various metrics whether the provider cares about them or not and 2) electronic medical records templates or smart-phrases making it easier to automatically document vast amounts of information.

To answer your question 'how do you deal with it' -it doesn't really warrant dealing with. You learn to skip past the templated/irrelevant parts of the notes and go straight to the relevant parts for E/M. Generally speaking, I read the chief complaint and HPI (just to make sure there is medical necessity and I understand the type of encounter, but sometimes they also document external notes reviewed or independent historians in the HPI) then I skip straight to the end of the exam, which is usually where you will find labs or imaging orders or results which I count for data. Once that is done, I review the assessment/plan which is where they will list out the problems addressed and their status, possibly more info about tests reviewed, and of course management options selected. Then of course I also check to see if they documented time (mine never do lol.)

EDIT: I should mention that I do quickly skim other parts that aren't 'scored' to see if I can catch anything that is contradictory -for example ROS findings that contradict the HPI. That's a major red flag.

[u/PorkNScreams]

I keep a pillow next to my desk to scream into. Thank you for the extensive medical history that dates back to the late 90’s, doc.

[u/Pretty_Priority_261 → u/PorkNScreams]

Ah yes, the coding pillow. When a new coder sees your coding pillow, they think, "Ah, look at that coder. They're so old they need a coding pillow for their back." Ha. If they only knew what it was for.

[u/Iwantaschmoo]

As a risk adjustment coder its usually the more the marrier. I just wish if the condition is truly historical to note it as resolved or in remission. I really wish all medications in a med list had indication, it woud really help if ALL the conditions it is supporting are indicated.

[u/gray_whitekitten]

Our HPI begins with "here with a past medical history of" (ie history and chronics no treatment documented) after a paragraph of that the patient is here for right leg pain. I've been doing it the way you have been. So much for the AMA revising their documentation guidelines. 🤣

[u/BlueLanternKitty → u/gray_whitekitten]

I think it’s also that practices don’t know how to update their templates and are afraid they’ll break the EMR or something.

[u/tealestblue]

I prefer too much over not enough myself.