No Complaint vs Normal in EHR Documentation

I was recently talking to someone about why EHR documentation is so awful to read. It’s because billing requires that the doctor spew out all this useless documentation in order to justify billing at a higher level (Side Note: Be sure to check out my previous post about Documentation by Exception Being the Dredge of EHR Documentation).

As I discussed this challenge with clinical documentation, this person told me that their doctors don’t mark everything as normal. Instead, they marked all of these systems as “No Complaint” (or something along those lines). Basically, the patient didn’t complain about that system. I didn’t really check it to know that it’s normal, but I didn’t notice anything abnormal and they didn’t tell me something was wrong.

Hopefully some of my readers that are billing experts can let me know if this type of documentation would fly in the US as far as getting reimbursed. Everyone I’ve seen has always marked it as normal. My guess is that for billing in the US just saying that the patient didn’t complain about a system wouldn’t get you reimbursed for evaluating that system.

However, the person I was talking with was not in the US and so he didn’t have to worry about the billing requirements that we have to worry about. My question to him was, “Then, why in the world are you documenting that the patient didn’t complain?” It seriously made no sense to me. You can basically assume that if you haven’t documented a system, then the patient didn’t complain about any system that’s not documented. Why would you clutter the medical documentation with all of these “Patient Did Not Complain.” That feels even worse than saying that everything was “normal” (unless we’re talking from a liability standpoint).

Maybe my trusty readers can give me some idea of why it would be worthwhile to document all of the “No Complaints.” Am I missing something? Is there some clinical value to it? Seems like a negative to me. Let me know in the comments if you know something I don’t know or if you agree with me that documenting “No Complaints” is a waste of clinician time and actually is worse than not doing it. I look forward to hearing your thoughts.

About the author

John Lynn

John Lynn

John Lynn is the Founder of the HealthcareScene.com, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference, EXPO.health, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.

10 Comments

  • Evolutionary time-line…
    In the earliest days it was sparse/terse and mostly for the benefit of the clinician:

    1. Document the decision and treatment. (Otitis media – amoxicillin.)
    2. Document the decision, supporting evidence, and treatment. (Bulging red R TM, OM, amox.)
    3. Then it became necessary to document why other decisions and treatments were not elected.
    4. The SOAP note and problem oriented recording developed to encourage tracking problems over time. Still a clinical approach.
    5. The medical record slowly became a legal document. If you didn’t say you examined the calf and found no evidence of DVT, it meant you hadn’t done it and were liable.
    6. The medicolegal record slowly became a billing record. In order to prove how hard you worked, you needed to document two from column A, three from column B, level 37 decision making, an explicit statement of risk. This required documenting lots of negative detail. ‘Pertinent negative’ in a ROS became a laundry list of clinically irrelevant but coding-dependent negatives.
    7. Add meaningful use and other audit requirements, and there is another layer of information that must be acquired and recorded.

    In all this process, sadly, the note stopped being primarily a clinical tool. I fantasize about a system that allows recording of all that clinically unnecessary flotsam and jetsam, but does not require including it in a clinical note. It goes into the database and is accessible for those who want it when they want it, but it doesn’t get between me and my patients.

  • As a medical practitioner from Australia in the public system (with no billing needs from an EHR) I can say that documenting ‘No complaint’ is essential to the documentation of the diagnostic process. It works like this:-
    1. Patient describes symptoms for which there are many hundreds of potential causes. In the doctor’s mind this generates a list of important causes that need to be tested, one by one, against what the patient’s symptoms or signs are. This is the “differential diagnosis”
    2. The “differential diagnosis” is refined and narrowed down by asking about further symptoms. The absence of certain symptoms in the context of the symptoms the patient does have is then critically important in narrowing the diagnosis. The same applies for signs.
    3. The refined and narrowed “differential diagnosis” becomes the ‘working diagnosis’ at that point in time.

    We refer to ‘no complaint’ in the clinical record as ‘significant negatives’. A list of the contextually relevant significant negatives shows what diagnostic possibilities have been considered and tested from the history and examination. This is essential for all other doctors to know if involved in assessing a patient further. It is always possible that certain diagnostic possibilities have not been thought of and therefore not tested in the history or examination of another doctor and this is clear from missing ‘significant negatives’ for the clinical context. In this way diagnostic errors are identified early

  • Peter,
    Thanks for your comments. I’m going to share them more broadly on EMRandEHR.com tomorrow. The evolution is sad.

    David,
    I see your point. If indeed the doctor asked about something and the patient says that it’s not an issue, then I can see why the documentation would be valuable. However, that’s not what I’m seeing or hearing about in practice. In practice I seem them pulling up a template and marking everything as patient didn’t complain even though the doctor didn’t ask them if it was a complaint or not. I guess that’s the subtle difference from what you’re describing and what I think is messing up EHR documentation.

  • There are several practices in healthcare documentation which I thought you would have known by now. They are not abuse but real use.

    NAD: No abnormality detected
    NC: No complaints
    No CILCP: No Cyanosis, Icterus, Lymphadenopathy, Clubbing, Pallor
    etc.

    In allergies, on the other hand, we record : No known allergy/ Not asked/ allergic to…
    The diff being that no known allergy is a significant statement. But if the case was comatose, or a baby with no guardian etc. allergy history could not be elicited and therefore, we write Not Asked.
    These are important negative findings and No Complaint in an organ system is also in that category. Don’t raise a flag where none is needed.

  • …And BTW let it not be fashionable to keep doctors’ practices in the dock at every micro level.

    Your statement ” In practice I seem them pulling up a template and marking everything as patient didn’t complain even though the doctor didn’t ask them if it was a complaint or not.” looks like one is hell bent on finding a loophole in this No Complaint thing.

    When my patient is done with his main complaint, i usually ask them “What else” and sometimes a pointed question related to the current compliant. (e.g. a case with fever and runny nose should still be asked about burning in urine. But i will not ask him about every other system pointedly. And if the pt. is “Nothing else” , well then it is nothing else.

  • Time for more “WhatIfs”!

    Whatif the clinician’s documentation didn’t determine the billing code and how much the encounter will be reimbursed?
    Whatif there was no chance of a liability issue subsequently arising from that encounter?

    From Peter’s listing of documentation chronology, it would be:
    “1. Document the decision and treatment. (Otitis media – amoxicillin.)”

    From healthcare informatics 101, the purpose of patient records are:
    1- Patient care
    2- Communication
    3- Legal documentation
    4- Billing and reimbursement
    5- Research and quality management
    6- Population health
    from Wager et al, “Health Care Information Systems” 3rd Edition 2013

  • John, I am wondering if you are confusing the ROS (review of systems) with the physical exam.

    In the ROS, the provider asks and the patient answers the problems he’s having relating to different areas. A provider may dictate “no complaint” for any areas which the patient says there are no problems. The provider cannot document “no complaint” if he never asked the patient the question.

    In the physical exam, the provider documents if the exam revealed a problem or is considered normal.

    A provider (in the U.S.) that reviews every single system and examines every single body area despite the patient’s problems will ultimately get dinged when Medicare and other payers decide (as many hospitals have already) that medical decision making (MDM) must be one of two key areas in order to qualify for a higher level of visit for any established patient. MDM is a required element for new patient, along with HPI and physical exam, but any two of the three elements are required for an established patient.

    Mary Pat

  • Dr Bhatia,
    I’m just repeating the mantra that I’ve heard from hundreds of doctors about the nasty, ugly, bloated EHR notes. You’re the first doctor I’ve seen which seems to like them.

    Mary Pat,
    You’re right that if they really started coming down on MDM, then this would help the situation. We’ll see how it evolves. I think the EHR vendors are going to have to code around this challenge.

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