We inform ourselves documentation is for affected person security. For continuity. For cover. However let’s be trustworthy. It’s for billing. And when you see that clearly, it’s arduous to unsee.
In coaching, I used to be taught that the observe displays the considering of the doctor. That it ought to inform the story of the affected person and the rationale for every choice. However in observe, it doesn’t. It’s a instrument for income seize.
Extra particularly: The longer and extra advanced the observe seems, the extra it justifies the code. So we inflate. We paste. We “good phrase” our means via nuance. And over time, we lose observe of what we have been even attempting to say.
I’ve seen good residents spending extra time optimizing templates than reviewing affected person historical past. I’ve watched attendings rush discussions as a result of “I have already got a dot phrase that covers that.” I’ve seen sufferers sit in silence whereas their physicians tried to reverse engineer which template would unlock a Stage 4.
This isn’t care. It’s simulation. A efficiency optimized for compliance, not therapeutic.
We are saying the observe is for reminiscence. However that may be a lie too.
Sufferers not often learn the notes. Colleagues not often belief them. Billing employees use them as a protection. The EMR turns into a sport of believable deniability: “If it’s not within the observe, it didn’t occur. Whether it is within the observe, I’m lined.”
However how many people have regarded again at our personal notes and had no concept what we meant? What number of occasions have we reread our documentation and realized the actual decision-making by no means made it in?
Documentation, in its present kind, will not be reminiscence. It’s paperwork disguised as security.
So what can we do?
Some attempt to write “higher notes.” Others attempt AI scribes, or rent scribes, or use templates layered on templates. A few of us simply quit and paste no matter satisfies the system.
However the bigger reality is that this: We don’t want higher notes. We’d like a greater system of reminiscence. One which honors the scientific story, protects the affected person, and respects the time and cognition of the doctor.
I’m nonetheless working via how a lot this broke me. The late nights. The hidden stress. The fixed stress between telling the reality and getting the code. However I’ve come to imagine that therapeutic the system begins with reclaiming the narrative.
The observe shouldn’t be a weapon. It must be a shared artifact of care. And perhaps, sometime, will probably be once more.
Sriman Swarup is a hematology-oncology doctor.
