By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“If it wasn’t documented, it didn’t happen.”
     -Aphorism passed on to all health care providers in their training

One of the promises of Electronic Health Records was that it would make medical information more legible, and complete.

While computer text is undoubtedly more legible than most handwritten clinical notes, it does not solve the issue of incompleteness, and may make it worse. A long progress note can be created using templates and short-cuts, but sometimes a clinician fails to record the core information of the history of present illness and the part of the physical exam relevant to that complaint. When this happens, anyone reviewing the record would come to the conclusion that the quality of care in that visit was poor and unacceptable.

For example, a patient comes to the office complaining of back pain. The progress note includes a depression/anxiety screen, smoking history, alcohol history, review of current medications, and the medical assistant’s note of the chief complaint of back pain, for the past week since moving a heavy couch. The clinician documents no further history, and the physical exam notes that the heart sounds are normal, the lungs are clear and the patient is in no acute distress. There is no recorded back or neurological exam. The assessment is back pain, and an MRI is ordered.

This electronic medical record generated note not only gives the Partnership HealthPlan of California (PHC) medical directors no details by which to judge the medical necessity of the MRI request, it reflects either poor quality care by the clinician, or poor documentation by the clinician, and possibly both.

The consequence of this: a denial of the MRI request, the need for a repeat visit to do the relevant history and physical exam, and a delay in getting appropriate care for the member.

This issue is definitely not universal. In the process of conducting utilization management reviews and investigations of potential quality of care issues, we also encounter very complete and appropriate documentation that reflects a logical collection of historical information, a thoughtful physical exam and a delineation of the differential diagnosis considered.

Sadly, we encounter many progress notes that incompletely address the reason for the patient’s visit. When we bring this to the attention to the Medical Director of the organization, they are often unaware of the issue. This is perhaps even more concerning, that health care organizations don’t closely monitor the quality of medical records and clinical decision making.

One of the best resources to offer a clinician with poor documentation practices is the UC San Diego PACE Medical Record Keeping course. Having your clinicians periodically audit each other’s charts is another way to promote attentiveness to the quality of medical recordkeeping and clinical decision making. Having a standard set of review criteria is important; Family Practice Management has an article on this topic.

Physician Assistants are required by the Medical Board to have a percentage of charts reviewed by their supervising clinician, a good opportunity to identify poor documentation practices. Although physician review of a sample of Nurse Practitioner Charts is not required by the State of California, it is also a best practice to do this on at least an annual basis, as part of a yearly performance evaluation.

One final note: excellent documentation practices help prevent medical liability lawsuits and licensure actions by California Medical Board/Nursing Board. It is better to have a system to improve documentation and decision making before such actions force the issue.

For a collection of de-identified humorous examples of actual medical records PHC has reviewed, see Dr. Jeff Ribordy’s blog.