As family physicians in the 21st century, we practice in an era of accelerating communication and expanding expectations. Partners, consultants and staff depend on our notes to effectively extend care, while patients may – and increasingly do – peer into the documents we create about them. Because of this common interest and potential scrutiny, our medical records need to furnish clear collegial communication and assure patients that their best interests are actively safeguarded.
Given the demands and pace of modern practice, pen and paper alone are no longer adequate tools for surmounting the challenge of compiling clear, concise and complete records. However, most physicians are not yet ready to embrace electronic medical record systems, for varied and often legitimate reasons. That leaves many of us somewhere in the middle of the documentation spectrum, taking handwritten notes during our encounters, dictating those notes at the end of the visit or the end of the day, and then having our notes transcribed and printed into legible records. While this method of documentation is both expeditious and reliable, its benefits can be magnified through one simple change: transferring the location of dictation from behind closed office doors to within exam rooms. Combining dictation with patient contributions advances documentation and improves your practice in at least seven important ways.
Documenting patient visits after their conclusion can be slow and frustrating as you try to recall specifics of the encounters.
With patient-present dictating, your work is done when you leave the exam room, allowing you to focus your attention completely on the next patient.
Dictating in the presence of your patients, who can correct or supplement your information, improves the quality of your records, resulting in improved reimbursement, malpractice protection and patient care.
Physicians are notorious for creating rushed, illegible notes – an ignominy that corrodes communication and sours staff relations. Given that most industries and professions have abandoned handwritten records, it’s mystifying that medicine continues the practice. Perhaps this anachronism was derived from our guild heritage. Ever wary of competition, medieval practitioners of the healing arts shrouded their incantations and remedies in indecipherable script. This secretiveness purposely concealed knowledge and thwarted communication. As a residue of the guilds, illegibility still serves to cloak competence, though more frequently to camouflage uncertainty than to hide the secrets of our clinical success.
Other than aggravation, illegible notes serve little purpose today. Readers bypass their content, and patients lose their potential benefits. Patient-present dictating aims for clarity and repeatedly reveals physician competence – audibly to the patient during the record’s creation and legibly to future reviewers.
Consider records spoken in front of patients as records built with patients. Your rationale and plans will emerge in a more readable document; your medical reasoning will be more readily retrieved during subsequent visits; and your colleagues will be less hindered when assuming care (patients aren’t the only ones stumped by inaccessible terminology).
Delayed documentation is a slow and frustrating task that erases the distinctions between patients and the specifics of their encounters. Toting around and sorting through a morass of data on all the patients you’ve seen in a day accounts for a substantial waste of effort. Patient-present dictating frees you to focus your undivided attention on each patient, efficiently closes each visit and clears your mind for the next patient.
Because we tend to speak faster than we write, dictation within the exam room reduces the time spent recording care. Incorporating dictation into the patient interview saves even more time. For example, rather than searching the chart for changed or missing information, invite patients to speak telephone numbers, birth dates, addresses, etc., directly into the recorder (they’re almost always happy to oblige). Also, since most of us already repeat advice and instructions to patients until they are clear, simply recording while repeating those pertinent highlights doubles the benefits: patients hear clarifying advice while our documentation concludes.
A medical record that mirrors the entire encounter frequently warrants a higher-level evaluation and management code than a medical record that captures only the portions of the encounter we can recall from our notes. Medical billing is largely Byzantine. Reimbursement must percolate through the convolutions of history collection, physical examination, procedure performance, documentation and coding. Along the way, it can be reduced or delayed depending on the completeness of our documentation. Because it’s difficult to remember and sort history and exam details from patient to patient, delayed documentation compounds information attrition and consequently reduces reimbursement. Dictating in the patient’s presence prompts full and accurate reflections of care by capturing the details of your encounters in real time while patients listen and supplement your notes.
Income can seep from many sites within a practice. Economists describe these sources of loss that are difficult to define or measure as externalities. For example, illegibility can cost your practice time and money by spawning hieroglyphics-deciphering huddles of exasperated nurses, receptionists and colleagues. Externalities within medical offices also include the disruptive errands that staff members perform in pursuit of wayward records. Consider how much time is wasted in the quest for charts sequestered by documentation delays. Patient-present dictating ends chart archaeology and attenuates income loss from office externalities.
4. Malpractice protection
Dictating notes in the patient’s presence fulfills three cardinal features of malpractice risk reduction: Records are contemporaneous, patient witnessed and patient approved. Charting completeness and accuracy increase as patients are invited to amend or correct the information as it is produced.
Building the record with the patient assures later reviewers that the patient understood expectations, confirmed consent and agreed with the care plan. Clear statements of shared responsibility (for example, “Signs of wound infection reviewed. She understands and agrees to return immediately if any occur”) pierce perceptions of negligent care.
This documentation method also avoids anger by erasing the impression that you are speaking behind patients’ backs (when you dictate out of earshot, that is exactly what you are doing). And it discourages you from putting offensive data about a patient into his or her medical record, which could cause legal trouble down the road. If you don’t want the patient to hear it during the encounter, then you surely don’t want the patient’s attorney to read it later.
5. Improved care
In most clinical situations, medical care begins rather than ends with the doctor’s appointment. As the amount of material we cover per encounter has markedly increased, our attention to patients’ individual concerns has become restrained, effectively pushing patients toward more self-care. Patient-present dictation helps you build and review care plans with your patients. This compels understanding, encourages compliance and smoothes the transition to increased self-care.
This collaborative approach not only reflects the realities of modern practice, but it also reveals and reinforces the intentions of both parties. Patient-present dictation helps the patient understand the decision he or she has made and allows you to give your audible imprimatur to the patient’s plans. For example: “High cholesterol treatment options reviewed. He chooses to pursue a low-fat diet and daily exercise program. I endorse his plan.” Dictating in the patient’s presence is also an excellent tool for confronting addictive, abusive or detrimental behaviors. It demonstrates that you consider the patient’s illness and actions serious, it cuts through disease-specific denial by requiring you to speak the clinical details into the record as the patient listens, and it enters patient-confirmed limits into the record (for an example, see the sample note).
Nearly all encounters improve with patient-present dictating. However, this technique may be inappropriate when dealing with an already angry or easily provoked patient, when a patient with acute mental confusion would misinterpret the purpose of compiling care details, or when the patient would not want another person in the room to hear the information.
A SAMPLE NOTE
The following is an example of how a physician might dictate a note in the presence of a patient. Notice that its content differs little, if any, from what a written note might contain. Notice also that it follows an extended version of the “SOAP” format. (For more information on “SOOOAAP,” see the author’s previous article titled “Documentation Tips for Reducing Malpractice Risk,” FPM, March 2000, pages 29–33.)
Subjective: PM is a 42-year-old mother of three here to review smoking cessation after being advised to stop smoking during previous office visits. She began smoking at age 15, smokes one pack per day of a generic brand, can go up to six hours between cigarettes and unsuccessfully attempted to quit one year ago with over-the-counter nicotine patches. No seizure history and no other illicit drug use. Not currently using other medications. Five years ago had colposcopy and cryotherapy after abnormal pap. Her partner and children are encouraging her to quit. There are no other in-home smokers, and her work is now enforcing its smoke-free policies. Both parents smoked. Father died from heart disease at age 66. Mother has hypertension and osteoporosis. Two children with repeat otitis diagnoses.
Objective: Friendly, appropriate in conversation. Lungs without wheezes, rhonchi or crackles, though mildly prolonged expiratory phase. Heart regular rate and rhythm, no murmurs. Neurovascular exam without deficits. Dentition and skin with positive tobacco stigmata. Pulmonary function tests reveal FEV1 and FVC at 90 percent.
Opinion: Tobacco dependence with family, occupational and health impacts.
Options: Reviewed repeat trial of nicotine replacement, bupropion, group quitting program, “smoking by the clock” and “smoking by location.”
Advice: Advised combination of options with close follow-up. Reviewed links between smoking and cervical cancer, heart disease, osteoporosis, skin and teeth changes and otitis in children. Advised she continue with regular pap exams.
Agreed Plan: I congratulated her choice to stop smoking. She wants to avoid medications and group involvement for now. She set a quit date for two weeks from today and will keep her follow-up appointment for two days after that date. She will taper nicotine usage with smoking by location and by the clock before quit date. Relapse advice and precautions reviewed. Patient education handouts given. Reminded her of other quitting options should the need arise. Dictated in the patient’s presence.
6. Patient satisfaction
Though it is difficult for patients to assess a physician’s medical knowledge and clinical skills, they can gauge your interest and listening skills. By combining dictation with clinical care, we spend more time sitting down with patients and listening to them. And when we clearly recite the details of patients’ concerns back to them, we confirm our focus on their well being. Besides satisfying patients, this approach also satisfies physicians. Statements such as, “Wow, you were really listening!” or “I can’t believe you remembered all that,” are frequent rewards for those who dictate in their patients’ presence.
Modern medical care is a commerce of attention. Patients not only strive to be heard, but they are also curious about what you think and how you present them to others. Patient-present dictating directly demonstrates your attention and shares your thoughts.
Being invited into care is new to many patients and sometimes requires an introduction. With new patients, I preface patient-present dictation this way: “Because you own the information in our charts, I want you to know exactly what is going into your medical record. I’d also appreciate it if you’ll listen closely and correct me if I make any mistakes or leave anything out.”
We increasingly face interruptions and distractions that whittle away at the core of our profession: spending confidential time with patients and their families. Patient-present dictating restores and protects this time without markedly altering current documentation practices. New skills are not required. They only need to be modified slightly and applied in a different location.
Breaking with tradition
While the conversion from your current documentation custom to dictation in the presence of your patients is relatively simple, it will require that you stretch your imagination and consider a new approach. “The way we’ve always done it” in health care isn’t necessarily the best way, and we must be willing to explore new ground. By dictating alongside your patients, you will spur improvements throughout your practice and both you and your patients will soon reap the many rewards.