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The Clinical Documentation Conundrum

By smace@healthleadersmedia.com  
   February 01, 2017

As one example, Erskine says Epic "is going to make at least provenance within their record more front and center, so if I hover over a term in the record that was copied from somewhere else, it will tell me who was the originator of that particular term."

"Presumably, if I'm communicating well because I'm writing good notes and if I'm coordinating well because I'm working with other institutions, and I'm managing the patient well—that's the measure of success, as opposed to what I've actually done and how many times I've ordered something and how many elements I've put into my clinical notes," Erskine says.

"More documentation expected from the physician and more focus on quantitative markers as surrogates for qualitative outcomes is our problem."

Badlani recommends one approach to make sense of the "note bloat" of today's EHRs in the coming value-based, team-based world of care is to rearrange the typical SOAP (subjective information, objective information, assessment, and plan) note into an APSO note, with the assessment and care plan coming first. "When I'm looking at another physician's note, I really want to see their assessment and plan," Badlani says. "And the reason you still maintain the subjective and objective elements at the bottom of the note is because you need them for compliance, for billing, and for coding standards, and then nobody looks at that except whoever is making sure you are billing appropriately."

As much as steps such as these can help, Badlani still sees the same documentation crisis as others do. "More documentation expected from the physician and more focus on quantitative markers as surrogates for qualitative outcomes is our problem," he says.

Sutter is looking to adopt from other healthcare systems in the clinical documentation picture. "In some organizations, they have standardized the way radiologists or pathologists document," Badlani says. "I, as a consumer, know exactly where in the document to expect what." Combining such standardization with a change from SOAP to APSO, would allow physicians to more quickly find what they are looking for within the EHR, he says.

Scott Mace is the former senior technology editor for HealthLeaders Media. He is now the senior editor, custom content at H3.Group.


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