Monday, August 31, 2015

P4P

For those of you not in the field, quality medical notes in the U.S. have been replaced by bullshit "Quality Metrics."

Instead of an intelligent statement on the patient's condition, you have to make sure that your note includes specifically worded stuff - which usually has absolutely nothing to do with what's going on.

The idea is that if you don't say these required phrases then you must not care, and (also importantly), may not got paid by insurance. So docs have to put crap like this in their notes.

Anyway.

Last Friday I received a consult on an 89 year old guy who suffered a cardiac arrest at home on Monday. He'd since been on a ventilator, and clearly wasn't waking up. So neurology was needed to decide if he'd recover (yeah, I know, but that's a whole 'nother post).

Leafing through the chart, I saw this note, written on Thursday night by an internist:


Sigh.

25 comments:

John Woolman said...

Glycated Mercury with no units specified.. Deary me!

skidmark said...

Obviously internists are able to raise folks from a coma, if not from death itself - at least long enough to counsel them about their A1C.

But what absolutely flabbergasts me is that said intern did not prescribe a diabetic diet or start the patient on any of a number of "routine" medication regimes.

That's like the ortho doc coming by, looking at your ulna sticking through the skin and saying "Yep, it's broke" and walking out the room never to return.

stay safe.

Anonymous said...

"I tell my comatose patients to take better care of themselves, but do they listen? No. Do they do anything to take responsibility for their own recovery? No. Why do I even bother?"

Candida Gomez said...

I have opinions about one-size-fits-all fill-out-the-form measurements of things like medical care (and education). Checking all the tick boxes does note mean the patient is receiving quality care; sometimes the best care is those few extra minutes that show the doctor is a Dr. Grumpy, who cares about you as more than a condition and income source.

J said...

Don't you just love government involvement in your healthcare?!

Anonymous said...

93 y/o demented patient diet controlled diabetic (A1c 5.9) went in the hospital for atypical chest pain. Came out on QID insulin, high dose Lipitor, two anti-hypertensives (couldn't stand up without blacking out). All done to meet quality measures.

Anonymous said...

reminds me a cartoon where the doc comes out and says, "We couldn't save him, but I was able to lecture him about diet and exercise one more time.
As a primary care doc, it drives you crazy to get these 5 page notes and have to find the one sentence that actually means anything so far as patient care.

The Condign Gentleman said...

"Also asked the patient if he was aware of his insurance company's partner offers in life insurance, vacation timeshares, and credit cards."

bobbie said...

What utter and complete bullshit!

ndenunz said...

The most pressing question is, what is the PSA?

Anonymous said...

"The most pressing question is, what is the PSA?"

And does this patient feel safe in his home?

Loren Pechtel said...

Wouldn't things like this be malpractice bait as it shows the doc is lying on the chart?

Anonymous said...

I wonder if the patient was asked about his seatbelt usage and if he owned any guns.

Daveycracker said...

Reminds me of the "metrics" that major pharmacy chains started implementing several years ago. Wasn't about making sure the patients were taken care of, it was about working as fast as possible to get them out of the store no matter what was going on.

Anonymous said...

Does he wear a helmet when he's on his bicycle?

Does he have any loose area rugs in his home?

And on and on . . .

Stacey Gordon said...

You will enjoy this: http://www.kevinmd.com/blog/2015/08/health-care-documentation-is-terrible-heres-why.html

PGYx said...

Now that's high performance!

Quality metric bars are set in all the wrong places these days.

Anonymous said...

My father just passed away, very quickly, from lung cancer spread to the liver. He was bright yellow and clearly in liver failure. He also was a type II on insulin. The Hospice doctor told me to monitor his sugar level. I am not a doctor, but could clearly see he was at the end. The last thing I cared about was a glucose level of 225. He went quietly in his sleep one day after an "official" diagnosis that it had spread to his liver. Hey doctors, people are not supposed to be yellow. IF he had went to the hospital when I begged him to, MAYBE they could have prolonged his life.... MAYBE.

Moose said...

Huh. Just earlier today I was reading about a case study of a man who developed extreme hyperglycemia and DKA after having an MI. Compounding it was that he had a fluctuating insulin resistance, which meant that his insulin needs were changing from day to day (if not hour to hour). His situation resolved after having a coronary artery bypass graft.

Of course, that doesn't help your poor fellow...

Anonymous said...

I work in CMH. I get to write monthly in my client's charts that my client did not die. Given that if that happened there would be a boat load of paperwork, I would think it would be obvious. But instead I get to spend time every month documenting this and other ridiculous things.

Anonymous said...

I'm sorry about the man with liver failure. I was just thinking today of my father that passed away a 3.5 years ago from pulmonary fibrosis, after using methotrexate many years for rheumatoid arthritis so that he could accompany his kids and grandkids climbing, spelunking, skiing, etc. and all the activities he tried to maintain over the years. Before he was admitted to hospice he had been using the public transport system with his portable oxygen to participate in swimming three days a week with his buddies.

As his body grew weaker and weaker his mind mercifully comfortably declined but I'll never forget when my sister the nurse was training my brothers to use a lift (draw?) sheet; one on one side and two on the other, to try and scoot him up in bed--which , and he had the temerity to holler, "Hey what are you bunch of monkeyshiners doing? If you tell me, I can help. Sheez." He hadn't eaten anything solid for a while, just sips of water, and someone brought in KFC. "Hey, I can smell that, let's all have a little fried chicken."

What a dear. I try not to think of how I miss him. He was a teacher in the 'territory' and still remember equipment in his classroom issued to the Alaska Territorial Schools. One of the items was utterly fascinating and probably interested me in science when we'd arrived with him early. It was a classic brass scale, with a little box of weights and tweezers.

The school where he taught and sisters attended a few years consisted of two buildings, with the playground in between, and in back was a high hill. When you're 5-6 years old and someone tells you to line up to go to class or the wolves in the hills may be looking at you, you run like the wind if you're ever told you need to see the principal in the other building.

He was an electronics technology buff and kept up with his ham operator license and darkroom from the Army and there were piles of Popular Science in the radio shack in the back of the house--and the back pages were not filled with girlie ads at the time. High-tech learning conisted of Grolier machines where you push a specially designed piece of paper into a device answer the question and roll up the page to reveal the answer in the opening.

I'll never forget him carrying on to my mother, a one-room teacher from New Hampshire, grumbling, and grouching when a public address system was installed so that announcements could be made, or fire drills, etc. "I have enough classroom interruption as it is without having to contend with a squawkbox. Next thing you know they'll be listening in."

The thing is with those pre-loaded charts, you cannot just 'delete' the irrelevancy. Tons and tons of wasted hmmm not paper, but maybe eye fatigue and irritation trying to answer all the questions when all you do is document the patient weight or allergy to sulfa drugs.

a.generic doc said...

Has he been to East Africa or had contact with anyone with Ebola?

Does he exercise regularly?

Does he smoke?

Was he counseled on exercise and smoking?

You probably could find the answers to all these and many other useless questions in the chart, too because his internist wants to get paid.

Anonymous said...

Handwritten? You'd think a doctor would have a shortcut on his keyboard for those remarks by now.

clairesmum said...


In the mid80s we bought a new car - first time that model of Chevy had a 'computer" in the vehicle to manage such tasks as controlling the gas and air mixture going into the engine. Had terrible problems with sputtering, stalling, and gas mileage that fluctuated all over the place. Repeated trips to dealer for repairs - still under warranty.
They insisted nothing wrong with car - because "computer says everything is fine."
The idea that if there was a problem with computer (managing air and gas) that there could ALSO be another problem with the computer (not accurately recording what it had done) was beyond comprehension.
They reassured us that the computer said all was well. And then we knew - in 1987 in Maine - that the computer age was upon us and that all would not be well.
I am certain that the computer systems at ExpressScripts are directly descended from this primitive computer ancestor!

RehabRN said...

LOL! Our patient education template makes us pick how the patient responded.

My guess is your guy's understanding was poor d/t lack of consciousness. That really interferes with patient education documentation.

Don't worry, MDs can't bill for education, anyway, even if you do it.

The joys of outcomes-based healthcare.

 
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