Evolutionary Timeline of Medical Documentation

I’ve been kicking up some dust over on EMR and HIPAA about the awful EHR documentation that most EHR vendors produce (Full Disclosure: It’s not really the EHR vendors fault, but billing and other regulations). In response to my post, Peter Elias provided a great look at the history of medical documentation and how we got so far off track when it comes to using documentation as a clinical tool. Here’s his comment:

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.

Reading Peter’s comments made me wonder if we’re going to start having two types of notes. A clinical note and a billing note. That’s sad to consider that EHR vendors would spend their time coding their applications around the challenge of quality documentation.

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.


  • John,
    I think you just came up with the next”thing”in EHR physician documentation. If it was possible for the physician to document what and how they prefer so that what they deem is clinically significant in a note was the clinical documentation and from that a separate note was generated to please the billing/government aspects…eureka!!
    I don’t think it would be that difficult. For years, physicians dictating would use certain abbreviations and the transcriptionist could take 1/2 a dozen of these abbreviations and turn it into a thorough clinical note. It shouldn’t be that difficult to take that and create something electronic. I know of one product that allows the physician to document one input(note authoring workspace) which can generate several outputs (notes). In that case,one of the outputs could be the MU/ICD-10/ whatever other initiative compliant note and the other could make sense to the doctor. I see the struggles of physician who just want to see their patients (especially older docs) and having this functionality would allow them to do their thing in addition to fulfilling all other requirements.
    Thanks for making me think this morning!

  • Susan,
    Glad you liked the idea. I honestly don’t think that EHR vendors will have a choice. They’ll have to do something to combat these bloated notes.

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