Our hospital has utilized EHR documenting for several years and the way it’s set up, the nurses are documenting only facts vs. subjective comments. Examples are, check boxes or drop down boxes with multiple choices or they’re entering numbers, ie; vital signs, I&O, etc. Within our EHR system, there is very little opportunity for them to document “text” in the subjective, thereby lessening the chances of inadvertently interjecting their own personal thoughts, feelings, or impressions, etc.

Physician progress notes have been one of the biggest culprits our payors use to hang their denials and upholds on, and usually, rightfully so. I’ve seen MD’s write progress notes that state, “Cardio workup and labs today for surgery tomorrow.” This patient was “admitted” for a work up for an outpatient procedure.

I’ve also seen things like, “Pt. wants to go home. Hemodynamically stable. Will dc home Monday.” and this was written on a Friday. But, because it was the weekend and the covering MD wouldn’t discharge an attending’s patient, the case manager was left with trying to ‘scrounge for criteria’ to make the two days meet for continued stay or the hospital takes a hit with a certain denial. And of course, it also affects length of stay (LOS). The reduction of LOS, has largely been placed on the shoulders of our UR nurses and case managers. They have done all they can to ensure a safe, timely and cost effective discharge. But, even with all of their efforts, at the end of the day, they are not the ones writing the discharge orders.

I do know there are some doctors who will work with case managers to shorten LOS, make sure the patient is in the appropriate LOC and assist the case manager by thinking” discharge” on admission, I find the majority have not and will not change their documentation style, especially based on anything the nurse(s) might be documenting. And it’s not one specialty. It’s across the board in all specialties.

I’ve been in this position over 10 years and while I do see that we are making headway, it’s been a very, very long, slow and arduous process. Even with the headway we’ve made, for the most part, it is still the MD’s documentation, not the nurses’ that ‘hang us’ when payors issue and uphold denials.

Thanks for your comments, physicians generally like the EHR for the fact of convenience and ease in documenting in the chart. The downside is documentation of their clinical judgment and expression of their cognitive skill sets including amount of work performed, clinical rationale, and clear picture of their medical decision-making is missing from the work. Thus, the increased number of medical necessity denials for admission and even denials in the ER itself.

Thank you for your comments on my most recent post. In a small hospital where the care manager tends to wear a disproportionate number of hats, it is unfortunately not always feasible to round with every physician given the time constraints. There are physicians who make rounds at 5 AM and some make rounds at 8 PM with only once case manager. Physician and nurse education education and reinforcement on the importance of documentation that reflects and encompasses clinical thought processes,judgment, actions and medical decision making is ongoing. Headway is certainly being made moving forward on this front.

Thanks again for your comment