Commentary

Short and sweet: Writing better consult notes in the era of the electronic medical record

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After 4 decades of clinical practice in a teaching hospital, I believe that the notes we write to document medical consultations are too long. When I review them for my own patients, the only part I read is the consultant’s assessment and diagnostic and therapeutic recommendations. Many of my colleagues and trainees do the same.

In the old days, when medical records were handwritten, the first three pages of my hospital’s four-page consultation form were for the history, review of systems, physical examination, and test results. The top two-thirds of the last page was for diagnostic impressions and recommendations for additional testing and treatment, to be completed by the trainee performing the consultation.

This left only the bottom third of this page for attestation and additional remarks from the senior consultant. Often, this last (but most used) page was just a bullet list of diagnostic possibilities and suggested tests and treatments, with nothing about the critical reasoning underlying the differential diagnosis and recommendations. This was probably the result of fatigue from having to fill in the first three pages by hand, and then having only limited space on the final page.

Even though the written record has been replaced by the electronic medical record in my hospital, consult notes continue to be at least as long as before, without any change in the length of the assessment and recommendations section. I would guess this is true in most institutions and practices that have switched to an electronic record system.

WHY ARE CONSULT NOTES SO LONG?

The main factor contributing to the lengthy consultation document is that the Center for Medicare and Medicaid Services, with other third-party payers following suit, ties the level of reimbursement to detailed documentation of the history (present, past medical, past surgical, medications, allergies, social, and family), review of systems, and physical examination in the consultation.1 Physicians are under constant pressure from professional fee-coders to meet these requirements.

Avoid repeating what is already in the record, but include your reasoning and teaching points

Since most of this information is already in the medical record, to require that it be documented again in the consultation note is unnecessary duplication. I believe that consultants comply with this requirement mainly to ensure adequate reimbursement, even though they know that the referring medical team will probably not read the repeated information.

Electronic medical record systems, which focus disproportionately on meeting insurers’ requirements governing reimbursement,2–5 have made it easier to create a lengthy consult note by checking boxes in templates and copying and pasting from other parts of the electronic record.2,6–12 Although verbatim copying and pasting may result in punitive audits by insurers, this practice remains common,13 including, in my experience, in consultations.

WHAT ARE THE NEGATIVE EFFECTS OF A NEEDLESSLY LONG CONSULT NOTE?

Time spent on repeating information—even if less time is required when using an electronic system—is clearly time wasted, since this part of the consult note is hardly ever read. Equally bad, the assessment and recommendations section in consult notes continues to be very short, probably because long-standing physician practices change slowly.

An ideal consult note has been described as one that, in addition to addressing the patient care issues, is as brief as possible, avoids duplication of already documented information, and has educational value to the person requesting it.14,15 The educational value of the consultation is especially important in teaching hospitals.

If the only part of the consultation perused in depth consists merely of lists of diagnoses, recommended tests, and therapy and does not include the consultant’s critical reasoning underlying them, the educational value of the consultation is lost.

HOW CAN THE FORMAT BE MADE SHORTER, YET MORE USEFUL?

The note should begin by briefly documenting the reason the consultation was requested. Ideally, institutions should train their staff to state this very specifically. For example, instead of “clearance for surgery,” it is better to ask, “Please identify risks involved in proposed surgery and suggest ways to reduce them.” The former steers the consultant to merely say “cleared for surgery, but with increased risk,” whereas the latter ensures a more specific and detailed response.

The consulting team must review in detail and verify the accuracy of all available information in the patient’s record. Once this is done, instead of repeating it, a statement that all existing information has been thoroughly reviewed should suffice, with mention in a separate paragraph of only the additional relevant positive or negative points in the history related to the issue the consultant has been asked to address.

The consultant shares with all users of the medical record the responsibility of pointing out and correcting any errors in the previously recorded information, thereby decreasing perpetuation of erroneous “chart lore,” an undesirable consequence of copying and pasting. If only previously unrecorded data and corrections to existing information are documented, the referring team is more likely to read the note because it points out relevant information that has been overlooked.

The main part should consist of a detailed assessment and recommendations section

The main part of the document should consist of a detailed assessment and recommendations section, which should include not only a list of diagnoses and recommendations for testing and treatment, but also the consultant’s reasoning behind them, the results of tests already obtained that support the consultant’s conclusions, and information of value for teaching and cost-effective practice. A critically reasoned assessment and recommendation section not only will prove very educational, but by challenging the consultant to justify his or her choices, may discourage unnecessary testing and questionable therapy4,14 and thereby contribute to cost-saving.

My suggestions would not shorten the time spent by the consulting team in evaluating the patient, but only eliminate redundant documentation. I believe the consultation document will be shorter but adequate for patient care, the referring team will read and use the entire document, its educational value will be enhanced, and the time spent on redundant documentation will be saved.

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