Emilio González, MD,
Professor of Rheumatology
University of Texas Medical Branch,
Explore This IssueJuly 2008
Also By This Author
For 40 years I practiced rheumatology as a solo practitioner. During those years, I followed your contributions religiously and appreciated your being “one of us.” In 2005 I closed my practice and joined the Clinical Documentation Improvement Program at St. Francis Hospital in Roslyn, N.Y. As you might expect, I had an inclination to comment on your article, “To Document or to Doctor?” For the last three years I have been part of a team that tries to encourage doctors at the hospital to document what they do to provide excellent medical care and part of the unit that regularly reviews the published Medicare documentation requirements in the Federal Registry. The latter rules and regulations are not an option. Contrary to general opinions, they are prerequisites not only for accurate billing (reimbursement) and accurate statistics and databases, but also are clearly designed to improve medical care by insisting on accurate diagnosis (when possible), matching treatment to diagnosis, and—importantly—improving communication between those numerous professionals involved in patient care. Given my last three years of experience with clinical documentation, I have several comments on your article.
Having been trained at major institutions from medical school (1952–1956) to 1964 when I went into practice—history, physical, review of symptoms, review of record, and complex decision-making—I think that these represent what goes into good medical care and only secondarily, in this era, reimbursement. If adding the words acute, chronic, systolic, and/or diastolic to the diagnosis congestive heart failure takes away from the care of the patient, one has to doubt the patient’s care. So, too, if adding acute blood loss anemia to the diagnosis of anemia, and if acknowledging a nurse’s note that the patient has a decubitus ulcer means that the doctor may actually have to turn the patient over in bed, then medical care is actually in doubt.
I could go on and on about accurate documentation and the quality of medical care, the accuracy of databases (number of line infections, pressure ulcers, and Foley catheter infections), and the inability of one doctor to follow what has happened to the patient from progress notes without adequate documentation.
I intended this comment only as perspective from the other side and to possibly refute the idea of documenting or doctoring.
Howard Weiss, MD
Clinical Documentation Improvement Program
St. Francis Hospital, Roslyn, N.Y.