Short and sweet: Writing better consult notes in the era of the electronic medical record
A CASE VIGNETTE
The following vignette (from my own subspecialty) of a patient with acute kidney injury illustrates how a consult note can be made shorter but more useful and educational.
A 78-year-old man had a history of long-standing insulin-requiring diabetes mellitus, hypertension (treated with lisinopril and amlodipine), and benign prostatic hypertrophy. One month earlier, his blood urea nitrogen level had been 15 mg/dL and his serum creatinine had been 1.2 mg/dL.
He presented with a 3-day history of vomiting, diarrhea, and fever, presumed to be viral gastroenteritis. His blood urea nitrogen level was 100 mg, serum creatinine 2.5 mg, and blood glucose 450 mg/dL. Urinalysis revealed 2+ albuminuria, 3+ glucosuria, and 6 red blood cells per high-power field.
In the emergency department he received 2 L of normal saline and regular insulin intravenously, and an indwelling bladder catheter was inserted. He was admitted after 6 hours.
Tests obtained on arrival on the inpatient floor revealed a urinary fractional excretion of sodium of 2.5% and a blood glucose level of 295 mg/dL. His admission history and physical listed his home medications as insulin glargine, amlodipine, lisinopril, and tamsulosin. It also listed the differential diagnosis for acute kidney injury as:
- Prerenal azotemia due to volume depletion
- Rapidly progressive glomerulonephritis to be ruled out in view of proteinuria and microhematuria
- Obstructive uropathy to be ruled out.
Ultrasonography the morning after admission showed normal kidneys and no hydronephrosis. The absence of hydronephrosis was interpreted by the primary team as ruling out obstruction secondary to benign prostatic hypertrophy. The nephrology team saw the patient in consultation the day after admission and discovered the following additional information: urinalysis done 6 months earlier had also shown albuminuria and microhematuria, and the patient had been taking over-the-counter ibuprofen 400 mg three times daily for several days prior to admission.
Table 1 compares consultation documentation in the usual format and in the format I am suggesting. The revised format has much more information of educational value (eg, the importance of reviewing past urinalysis results, asking about over-the-counter medications, factors affecting fractional excretion of sodium, effect of bladder catheterization on hydronephrosis due to benign prostatic hypertrophy, and measuring urine protein only after acute kidney injury resolves). It also encourages cost-effective care (ultrasonography could have been delayed or avoided, and the patient could have been cautioned about ibuprofen-like drugs to decrease the risk of recurrent acute kidney injury).
FINAL THOUGHTS
The modifications I have suggested in consult notes will be accepted only if they are reimbursement-neutral. I hope insurers will not equate a shorter note with an opportunity to lower reimbursement and will see the value in not paying for things almost never read. I hope they will recognize and pay for the effort that went into creating a shorter document that contributes adequately to patient care, provides greater educational value, and may promote cost-effective medical practice. Also, not requiring redundant documentation may reduce or even eliminate undesirable copying and pasting.
Accountable-care organizations are an important part of the Affordable Care Act,16 which went into effect in 2014. Many organizations had already come into existence in the United States before the act became effective, and their numbers and the number of patients covered by them are projected to grow enormously over the next few years.17
Since the accountable-care organization model will rely heavily on capitated reimbursement to contain costs, these organizations are likely to scrutinize and curtail the use of consultations. I believe that a shorter consultation note—yet one that is more useful for patient care, education, and cost-containment—is more likely to pass such scrutiny, especially if it decreases time spent on documentation. Furthermore, unlike the fee-for-service model, in a capitated-payment system it may not be necessary to lengthen consultation documentation just to ensure adequate reimbursement.
