Documentation Policies

Guiding Principles

  1. Physician documentation is a vital and essential part of the practice of medicine.
  2. The purposes of physician documentation are:
    1. To describe and document a patient’s story; to provide an orderly reflection of a patient’s symptoms and diagnoses, hospital course, and the physician’s thoughts and plans regarding that patient’s care.
    2. To improve the quality of patient care by facilitating continuity of care; to provide a source of communication between health care providers regarding a given patient’s diagnostic and therapeutic considerations and management plans.
    3. To provide documentation of the physician’s work for billing and reimbursement.
  3. Appropriate documentation involves being able to synthesize a diagnostic and therapeutic plan based on the historical, physical, laboratory, and radiological data.
  4. A thorough history and physical exam should be obtained for each new patient encounter (hospital admission, new clinic visit, new consultation) as appropriate for the specific situation.
  5. The extent of the documentation should inversely reflect the skill and experience of the author. Thus, a note from a medical student is expected to be longer than an intern’s note, which is longer than the senior resident’s note, which is longer than the attending physician note.
  6. One role of the faculty is to teach appropriate documentation to physicians in training.
  7. It is ultimately the responsibility of the faculty to ensure that adequate documentation of a patient’s course is occurring.
  8. The purpose of housestaff documentation is to facilitate excellent patient care and learning. It is recognized that thorough housestaff documentation may also facilitate the attending’s documentation of the necessary elements for billing but this is not the housestaff’s primary responsibility.

Specific Expectations

  1. Admission Notes
    1. Responsibilities
      1. Each provider involved in the admission of a patient to the hospital should document his or her involvement.
      2. On services with an R1:R2/3 pair, the senior resident is expected to write an admission note.
      3. It is acknowledged that on services with two R1s per senior resident, it may be impractical for the senior resident to write an admission note on each new patient. It that setting, it is recommended that the senior resident only writes a note on the more acutely ill or complicated patients.
    2. Content
      1. R1 and MS3/4 notes should be complete H&Ps following standard formats. (Students: see ICM II Pocket Guide for details)
        1. Identification/Chief complaint
        2. HPI
        3. PMH
        4. Review of Systems
        5. Social History
        6. Family History
        7. Medications/Allergies
        8. Physical Exam
        9. Summary of labs/studies
        10. Assessment and Plan: It is preferable to have an assessment be problem or diagnosis oriented rather than system-oriented.
      2. Senior resident notes should be a distillation of the pertinent positive and negative findings followed by an assessment that reflects a synthesis of all available data and is often in paragraph format.
        1. When senior residents are admitting patients by themselves, without an intern or subintern, then their note should be a complete H & P.
      3. Attending notes should reflect the attendings’ involvement with the patient, may link to housestaff documentation when appropriate, and should fill in details not reflected in housestaff notes. See CMS guidelines. UWP templates may be used to aid in creating a complete teaching physician note for billing.
      4. Assessment and Plan: An A/P is adequate when:
        1. A reader can scan the section and understand at a glance both what the problems are and what steps are planned.
        2. All the problems requiring written orders or clinical decisions are documented in order of importance.
        3. A thoughtful synthesis, relevant differential diagnosis, and logical management plan are present.
        4. A bulleted plan, following a thoughtful assessment, is also acceptable.
    3. Timeliness of the R1 Admission Note
      1. The complete admission note should be on the chart or in the EMR (Electronic Medical Record) as soon as possible, but not later than 7:30 a.m. before rounds, to facilitate review by the attending before post-call work rounds and other health care providers early in the day.
  2. Procedure Notes
    1. All procedures or attempted procedures need to be documented, including central line placement, arterial line placement, thoracentesis, paracentesis, arthrocentesis, lumbar puncture, and ACLS (code note).
    2. Documentation should include:
      1. Procedure performed
      2. Indications
      3. Summary of informed consent discussion
      4. Brief description of procedure
      5. Results of procedure
      6. Complications
  3. Progress Notes
    1. A daily progress note by a physician is required for all patients.
      1. Post call day – addenda for new admits; full progress notes for old patients.
      2. Progress notes are generally written by an R1 but may be written by a senior resident when there is no intern on the service, when the workload is being shared, or when there is an MS4 (subintern) taking care of the patient.
    2. Content of the Progress Note
      1. The progress note should summarize the patient’s current and interval clinical status.
      2. “SOAP” format is highly recommended: patient subjective information or interval history, objective information including pertinent physical exam and labs/studies, and problem- or diagnosis-oriented assessment and plan.
        1. “No events” is not considered an adequate interval history.
      3. “Litmus test” – could I read this note and assume care of this patient? Reader can determine the patient’s current clinical status AND the team’s thinking about what’s going on and what is planned
    3. Timeliness of the Progress Note
      1. It is recommended as a goal that Progress Notes should be present on the chart by 2:00 p.m. but at a minimum, they should be present by the end of the workday.
      2. The emphasis should be on early completion, with additional information, if necessary, added in an addendum.
        1. Example: “Addendum – GI consultant called. They have evaluated patient and plan EGD this evening.”
  4. Expectations for housestaff when there is an MS
    1. Admission note
      1. R1 should write a separate admission note.
      2. Senior residents should write brief addendum that is a distillation of the pertinent positive and negative findings followed by an assessment that reflects a synthesis of all available data and is often in paragraph format.
        1. It is acknowledged that on services with two R1s per senior resident, it may be impractical for the senior resident to write an admission note on each new patient. It that setting, it is recommended that the senior resident only writes a note on the more acutely ill or complicated patients.
    2. Daily progress notes
      1. Review MS3 note (the intern or senior resident can perform this role)
      2. Add/correct any missing/inaccurate information and initial the changes.
      3. Write a brief addendum that corrects inaccurate information, adds any missing information, and is a distillation of the pertinent positive and negative findings followed by an assessment that reflects a synthesis of all available data. This note is often in paragraph format.
  5. Expectations for the senior residents when there is a subintern (MS4).
    1. Admission note
      1. Review subintern note
      2. Add/correct any missing/inaccurate information and initial the changes.
      3. Write a brief addendum that corrects inaccurate information, adds any missing information, and is a distillation of the pertinent positive and negative findings followed by an assessment that reflects a synthesis of all available data. This note is often in paragraph format.
    2. Daily progress notes
      1. Review subintern note
      2. Add/correct any missing/inaccurate information.
      3. Write a brief addendum that corrects inaccurate information, adds any missing information, and is a distillation of the pertinent positive and negative findings followed by an assessment that reflects a synthesis of all available data. This note is often in paragraph format.
  6. Cross-cover notes
    1. Cross-cover notes are expected when a physician is called to see a patient for a significant event or change in status.
    2. Litmus test: “Will the primary team realize that I saw the patient, understand what I did and why, and be able to follow-up on anything required?”
    3. The note should provide a brief distillation of:
      1. The clinical issue for which the physician was called.
      2. Relevant subjective/objective information
      3. Assessment and plan
      4. Follow-up required
  7. Order Writing
    Residents must write all orders for patients under their care, with appropriate supervision by the attending physician. In those unusual circumstances when an attending physician or subspecialty resident writes an order on a resident's patient, the attending or subspecialty resident must communicate his or her action to the resident in a timely manner.
  8. Attending expectations
    1. Read notes prior to post-call rounds to facilitate efficient, educational post-call rounds
    2. Fulfill attending responsibilities for documentation
      1. These responsibilities are detailed in separate documents and in monthly orientations by the clinical chiefs of service.
    3. Provide timely feedback on content and quality of housestaff and student notes
      1. One important role of the faculty is to teach appropriate documentation to physicians in training.

Role of Templates

  1. The ideal template is a guide to good documentation, yet fosters the creation of a meaningful clinical note.
  2. It is recognized that the drive to capture all the required Evaluation & Management (E & M) elements for billing pushes us towards templates.
  3. Residents need to know what the requirements are for documentation. Education about billing is needed for graduates of our program.
    1. Possible venues: Intern Orientation; Resident Teaching Conference (lecture format probably the least effective method)