Consult Notes: Too Many Words, Too Little Information?

Gregory A. Hood, MD

Disclosures

March 11, 2015

Quality vs Quantity

The yin and yang of the consult note has always been one of the great conundrums of patient care. Consult notes rarely strike the perfect balance of volume of prose vs accessibility and meaningfulness of answers. Despite the excellence of today's consultants, even such fundamental issues as legibility and receiving an answer to the question posed in asking for the consultation often remain elusive.

Although electronic notes have helped legibility, they have also led to the creation of voluminous notes that regurgitate data ad nauseam yet add little to medical understanding or patient care. Frequently, a seven-page consultant note can be distilled down to one-and-a-half lines of italicized print, entered by the consultant, in the last half-page of the note.

One of my mentors during residency used a method by which an outline form of conclusions, considerations, and diagnostic/therapeutic recommendations that answered the questions from the consult request would lead off page one of the consultation. All of the historical information, findings, and E&M discussion were still contained in the note; they were simply listed after the section with the key answers. I believe that this can still be a viable approach, although many electronic health records (EHRs) won't permit this structure.

The above approach presents the requested answers right up front, and in a clear structure. In doing so, it overcomes an obvious failing of many consult notes today: They are too long. This excessive length probably leads to sections of consult notes not being read.

The explicit reason for the length of consult note is that the Centers for Medicare & Medicaid Services (CMS) and other payers peg their assessment of the amount of work done, and hence the valuation of the physician's work, to detailed, elemental narration of the history of present illness, medical and surgical history, review of systems, and examination. It remains beyond the capabilities of payers to truly understand the nuances of risk assessment and complexity of decision-making involved in patient care. Consequently, they reward the effort of dictation over the effort of abstraction. They reward the mechanics of the key logger over the mechanics of the thinking mind.

Garbage In, Always In

A related and all-too-common problem in the electronic age of the medical record is that there is a "garbage in, always in" effect. Accountable care organizations (ACOs) and other entities across the country have come to learn that the accuracy of diagnostic conclusions does not matter. Once a diagnosis has been entered for billing purposes—whether it be from the long-acquainted primary care physician, the nationally renowned consultant, or an urgent care or emergency department operating with zero prior records—it is golden, and it cannot be overruled or removed in any effective manner.

Eventually, diagnoses will fall out of the CMS database, as an example. No diagnosis, even an amputation of a limb, is truly forever. It takes several months at a minimum for this to happen. Unfortunately, because many physicians review the prior notes in order to create their own notes, once a diagnosis that is erroneous for any reason is entered into the chart, it tends to have a tenacious life of its own.

As an ACO medical director, I have reviewed my own data. For a 1-year period, I found that between 75% and 80% of my patients noted as having had an admission specifically for congestive heart failure (CHF) either did not have CHF as the reason for admission, or did not have CHF at all.

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