I received the following question from a colleague in the United States:
“In the US, payment is based on CPT codes which are determined by how many items are recorded in the examination.
This results in a system where “more is better”. A patient might simply have a small FB, yet the examination includes descriptions of the EOMs, lashes, optic nerve, mental status etc. (Not that in training they didn’t teach you that a good doctor did those routinely.)
With EHR, the ability to “default” normal items into the record can lead to 3 and 4 page eye examinations with elaborate descriptions of normal findings.
The ability to extract the pertinent material is hampered by the amount of useless verbiage.
My question is, “Does the use of EHR in Canada also result in such an explosion of words” or is the medical record more limited to what is useful?”
Here is what I said in response:
"In my EMR letter generating template, I have things set with such phrases as ‘the anterior segment exam was normal except blah blah blah.” The finalized letter also spews out extra information and I can easily select what to include and the rest gets automatically excluded in the finalized letter. The bottom line is that I never send out a letter longer than one page long.
Not sure if that’s what you were getting at? Hope that can help.
How do you deal with meeting documentation criteria with your EMR? Do you have checkboxes for normal parts of the exam? Do you have some default items already filled in then change them if the exam differs from the defaults? Do your generated letters included EVERYTHING from your data entry form?