Charting Requirements Interfere with Patient Care

Yesterday’s column on the burden of nurse documentation in the New York Times by Theresa Brown, RN was spot on. She details many of the rather onerous charting requirements mandated by myriad regulatory agencies and insurance companies. She laments the fact that the documentation is so time consuming that it takes away from her mission to care for the patient. She says that nursing has always been guided by the dictum “If it isn’t charted, it isn’t done,” and points out that charting everything a nurse does during a shift is impossible in reality.

The problem has been compounded by the electronic medical record which makes it easy to insert pop-ups and drop-downs so that anything some bureaucrat fancies can be added to the chart. Of course, the nurse still has to login and get past a number of screens before she finally reaches the section she wants. Here’s the bad news. Other than the bureaucrats and operatives from the Quality Assurance Improvement department, NO ONE READS THIS USELESS INFORMATION. It simply clutters up an already very “busy” electronic chart.

Like nurses, we physicians have similar, sometimes comical, charting responsibilities. For instance, the Surgical Care Improvement Project [SCIP]* has a relatively new rule that Foley catheters must be removed within two days after surgery to prevent infection. If the catheter is not removed, a progress note must be written documenting the reason the catheter was left in place. Recently, I was cited by “Thought Police” [Quality Assurance Improvement] spies because I failed to document why a catheter was still in place on the third post-op day. Never mind that the patient was on mechanical ventilation in irreversible septic shock, on vasoactive drugs with marginal urine output and died the next day. [As a side note, on researching this topic just now, I found that perioperative death is an “exclusion” regarding this measure. In other words, I should not have received a ding. I have forwarded the link to KGB HQ.**]

For years, we were told that Medicare wouldn’t pay the hospital if the medical coders listed anemia as a discharge diagnosis unless we wrote somewhere in a progress note that the anemia was due to blood loss after surgery. This was required even if it was patently obvious that the patient had undergone an operation and had lost blood.

I could go on, but I will spare you. A future blog will elaborate on the pros and cons of the electronic medical record.

*I have commented on the questionable value of SCIP here and here.

**Update. SCIP defines "perioperative" as the time between the end of the operation and discharge from the recovery room. Therefore, the citation stands. Of course, by that definition of perioperative, anyone patient dies in the recovery room would almost invariably be withing the first two postop days. So why bother to even mention it? Who knows?