Short and sweet:
Writing better consult notes in the
era of the electronic medical record
A
of clinical practice in
a teaching hospital, I believe that the
notes we write to document medical consulta-
tions are too long. When I review them for
my own patients, the only part I read is the
consultant’s assessment and diagnostic and
therapeutic recommendations. Many of my
colleagues and trainees do the same.
In the old days, when medical records were
handwritten, the rst three pages of my hospi-
tal’s four-page consultation form were for the
history, review of systems, physical examina-
tion, and test results. The top two-thirds of
the last page was for diagnostic impressions
and recommendations for additional testing
and treatment, to be completed by the trainee
performing the consultation.
This left only the bottom third of this
page for attestation and additional remarks
from the senior consultant. Often, this last
(but most used) page was just a bullet list of
diagnostic possibilities and suggested tests and
treatments, with nothing about the critical
reasoning underlying the differential diagno-
sis and recommendations. This was probably
the result of fatigue from having to ll in the
rst three pages by hand, and then having
only limited space on the nal page.
Even though the written record has been
replaced by the electronic medical record in
my hospital, consult notes continue to be at
least as long as before, without any change
in the length of the assessment and recom-
mendations section. I would guess this is true
in most institutions and practices that have
switched to an electronic record system.
■ WHY ARE CONSULT NOTES SO LONG?
The main factor contributing to the lengthy
consultation document is that the Center for
Medicare and Medicaid Services, with other
third-party payers following suit, ties the level
of reimbursement to detailed documentation
of the history (present, past medical, past sur-
gical, medications, allergies, social, and fam-
ily), review of systems, and physical examina-
tion in the consultation.
1
Physicians are under
constant pressure from professional fee-coders
to meet these requirements.
Since most of this information is already
in the medical record, to require that it be
documented again in the consultation note is
unnecessary duplication. I believe that consul-
tants comply with this requirement mainly to
ensure adequate reimbursement, even though
they know that the referring medical team will
probably not read the repeated information.
Electronic medical record systems, which
focus disproportionately on meeting insurers’
requirements governing reimbursement,
2–5
have
made it easier to create a lengthy consult note
by checking boxes in templates and copying and
pasting from other parts of the electronic re-
cord.
2,6–12
Although verbatim copying and past-
ing may result in punitive audits by insurers,
this practice remains common,
13
including, in
my experience, in consultations.
■ WHAT ARE THE NEGATIVE EFFECTS
OF A NEEDLESSLY LONG CONSULT NOTE?
Time spent on repeating information—even
if less time is required when using an electron-
ic system—is clearly time wasted, since this
CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 82 • NUMBER 1 JANUARY 2015
13
COMMENTARY
K.K. VENKAT, MD
Senior Staff Physician, Division of Nephrology
and Hypertension and the Transplant Institute,
Henry Ford Hospital, Detroit, MI
doi:10.3949/ccjm.82a.14008
Avoid repeating
what is already
in the record,
but include
your reasoning
and teaching
points
on September 3, 2024. For personal use only. All other uses require permission.www.ccjm.orgDownloaded from
14
CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 82 • NUMBER 1 JANUARY 2015
BETTER CONSULT NOTES
part of the consult note is hardly ever read.
Equally bad, the assessment and recommen-
dations section in consult notes continues to
be very short, probably because long-standing
physician practices change slowly.
An ideal consult note has been described
as one that, in addition to addressing the pa-
tient care issues, is as brief as possible, avoids
duplication of already documented informa-
tion, and has educational value to the person
requesting it.
14,15
The educational value of the
consultation is especially important in teach-
ing hospitals.
If the only part of the consultation perused
in depth consists merely of lists of diagnoses,
recommended tests, and therapy and does not
include the consultant’s critical reasoning un-
derlying them, the educational value of the
consultation is lost.
■ HOW CAN THE FORMAT BE MADE
SHORTER, YET MORE USEFUL?
The note should begin by briey document-
ing the reason the consultation was requested.
Ideally, institutions should train their staff to
state this very specically. For example, in-
stead of “clearance for surgery,” it is better to
ask, “Please identify risks involved in proposed
surgery and suggest ways to reduce them.” The
former steers the consultant to merely say
“cleared for surgery, but with increased risk,”
whereas the latter ensures a more specic and
detailed response.
The consulting team must review in detail
and verify the accuracy of all available infor-
mation in the patient’s record. Once this is
done, instead of repeating it, a statement that
all existing information has been thoroughly
reviewed should sufce, with mention in a
separate paragraph of only the additional rele-
vant positive or negative points in the history
related to the issue the consultant has been
asked to address.
The consultant shares with all users of the
medical record the responsibility of pointing
out and correcting any errors in the previously
recorded information, thereby decreasing per-
petuation of erroneous “chart lore,” an unde-
sirable consequence of copying and pasting. If
only previously unrecorded data and correc-
tions to existing information are documented,
the referring team is more likely to read the
note because it points out relevant informa-
tion that has been overlooked.
The main part of the document should
consist of a detailed assessment and recom-
mendations section, which should include not
only a list of diagnoses and recommendations
for testing and treatment, but also the consul-
tant’s reasoning behind them, the results of
tests already obtained that support the consul-
tant’s conclusions, and information of value
for teaching and cost-effective practice. A
critically reasoned assessment and recommen-
dation section not only will prove very edu-
cational, but by challenging the consultant to
justify his or her choices, may discourage un-
necessary testing and questionable therapy
4,14
and thereby contribute to cost-saving.
My suggestions would not shorten the time
spent by the consulting team in evaluating the
patient, but only eliminate redundant docu-
mentation. I believe the consultation docu-
ment will be shorter but adequate for patient
care, the referring team will read and use the
entire document, its educational value will be
enhanced, and the time spent on redundant
documentation will be saved.
■ A CASE VIGNETTE
The following vignette (from my own subspe-
cialty) of a patient with acute kidney injury
illustrates how a consult note can be made
shorter but more useful and educational.
A 78-year-old man had a history of long-standing
insulin-requiring diabetes mellitus, hypertension
(treated with lisinopril and amlodipine), and be-
nign prostatic hypertrophy. One month earlier, his
blood urea nitrogen level had been 15 mg/dL and
his serum creatinine had been 1.2 mg/dL.
He presented with a 3-day history of vom-
iting, diarrhea, and fever, presumed to be viral
gastroenteritis. His blood urea nitrogen level was
100 mg, serum creatinine 2.5 mg, and blood
glucose 450 mg/dL. Urinalysis revealed 2+ al-
buminuria, 3+ glucosuria, and 6 red blood cells
per high-power eld.
In the emergency department he received 2 L
of normal saline and regular insulin intravenously,
and an indwelling bladder catheter was inserted.
He was admitted after 6 hours.
The main part
should consist
of a detailed
assessment and
recommenda-
tions section
on September 3, 2024. For personal use only. All other uses require permission.www.ccjm.orgDownloaded from
CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 82 • NUMBER 1 JANUARY 2015
15
VENKAT
Tests obtained on arrival on the inpatient oor
revealed a urinary fractional excretion of sodium
of 2.5% and a blood glucose level of 295 mg/dL.
His admission history and physical listed his home
medications as insulin glargine, amlodipine, lisin-
opril, and tamsulosin. It also listed the differential
diagnosis for acute kidney injury as:
• Prerenal azotemia due to volume depletion
TABLE 1
Our patient’s consult note: The usual format and a more useful one
HISTORY AND WORKUP
Usual format repeats the history, physical,
laboratory, and imaging data already detailed
in the record.
The additional points about nonprescription
ibuprofen intake, urine fractional excretion
of sodium being obtained several hours after
receiving 2 L of normal saline, and past uri-
nalysis 6 months earlier showing albuminuria
and microscopic hematuria are included in the
repeated information and unlikely to be read.
Shorter, more useful format states the reason the consultation was re-
quested and that the history, physical, laboratory, and imaging data in the record
were fully reviewed.
These points are shown in a separate paragraph as important additional infor-
mation obtained by the consultant’s team. Thus, this additional information is
more likely to be read and its contribution to making the correct diagnosis noted
by the referring team.
ASSESSMENT
Usual format lists only the following:
Prerenal azotemia (due to gastrointestinal
fluid loss and renal fluid loss due to uncon-
trolled diabetes) plus use of lisinopril and
ibuprofen
Suggested format adds the following reasoning and educational information:
We had to ask the patient specifically about over-the-counter medication use
(very important to do in all patients with renal dysfunction) to learn about his
ibuprofen use, which might have contributed to prerenal azotemia.
Although high fractional excretion of sodium suggests acute tubular necrosis,
absence of granular casts in the urine sediment makes acute tubular necrosis unlikely.
Uncontrolled diabetes causing urinary loss of glucose with resultant osmotic natri-
uresis and diuresis and the fact that fractional excretion of sodium was measured
several hours after the patient was volume-repleted with normal saline can explain
the high fractional excretion of sodium in this patient presenting with prerenal
azotemia. The fractional excretion of urea in urine is more reliable under these cir-
cumstances. The high blood urea nitrogen-to-serum creatinine ratio (100/2.5 = 40:1,
normal 15–20:1), indicating nonnecrotic tubules reabsorbing urea while creatinine
is not reabsorbed, also favors the diagnosis of prerenal azotemia over acute tubular
necrosis. Rapid improvement in blood urea nitrogen and serum creatinine levels with
volume repletion in less than 24 hours will confirm prerenal azotemia.
Possible obstructive uropathy due to benign
prostatic hypertrophy
Absence of hydronephrosis in an ultrasound scan done 18 hours after insertion
of a bladder catheter does not rule out bladder outlet obstruction by prostatic
causes, since bladder catheterization may have rapidly reversed hydronephrosis
caused by benign prostatic hypertrophy.
Preexisting diabetic nephropathy Review of past urinalyses results by us (an important part of evaluating any pa-
tient with acute kidney injury, to determine if the urinary abnormalities antedat-
ed the present illness) revealed the preexistence of these urinary findings at least
6 months earlier. Thus, these urinary findings are unconnected to the present
illness. The most likely cause of these urinary findings is diabetic nephropathy.
Although microscopic hematuria is not typical, up to 10 red blood cells per high-
power field is not uncommon in diabetic nephropathy. Thus, rapidly progressive
glomerulonephritis is unlikely in this patient.
(Continued on next page)
on September 3, 2024. For personal use only. All other uses require permission.www.ccjm.orgDownloaded from
16
CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 82 • NUMBER 1 JANUARY 2015
BETTER CONSULT NOTES
• Rapidly progressive glomerulonephritis to be
ruled out in view of proteinuria and micro-
hematuria
• Obstructive uropathy to be ruled out.
Ultrasonography the morning after admission
showed normal kidneys and no hydronephrosis.
The absence of hydronephrosis was interpreted
by the primary team as ruling out obstruction sec-
ondary to benign prostatic hypertrophy. The ne-
phrology team saw the patient in consultation the
day after admission and discovered the following
additional information: urinalysis done 6 months
earlier had also shown albuminuria and micro-
hematuria, and the patient had been taking over-
the-counter ibuprofen 400 mg three times daily for
several days prior to admission.
TABLE 1 compares consultation documenta-
tion in the usual format and in the format I am
suggesting. The revised format has much more
information of educational value (eg, the impor-
tance of reviewing past urinalysis results, asking
about over-the-counter medications, factors af-
fecting fractional excretion of sodium, effect of
bladder catheterization on hydronephrosis due
to benign prostatic hypertrophy, and measur-
ing urine protein only after acute kidney injury
resolves). It also encourages cost-effective care
(ultrasonography could have been delayed or
avoided, and the patient could have been cau-
tioned about ibuprofen-like drugs to decrease
the risk of recurrent acute kidney injury).
■ FINAL THOUGHTS
The modications I have suggested in consult
notes will be accepted only if they are reimburse-
ment-neutral. I hope insurers will not equate a
shorter note with an opportunity to lower reim-
bursement and will see the value in not paying
for things almost never read. I hope they will
recognize and pay for the effort that went into
RECOMMENDATIONS
Usual format lists only the following: Suggested format adds the following reasoning and educational information:
Continue intravenous normal saline, avoid
nephrotoxic agents, hold lisinopril, and control
diabetes well.
Monitor blood urea nitrogen and serum
creatinine levels serially. If they do not return
to baseline or if they go up after the bladder
catheter is removed, repeat renal ultrasonog-
raphy.
Renal ultrasonography could have been deferred to see if these values returned
to baseline with volume repletion alone. Ultrasonography will be indicated only
if blood urea nitrogen and serum creatinine levels do not return to baseline with
correction of volume depletion or if they go up after removal of the bladder
catheter, because obstruction (hydronephrosis) will then have to be ruled out in
this patient with known benign prostatic hypertrophy.
Check random urinary protein/creatinine ratio
after acute kidney injury resolves.
This ratio is not reliable if done during ongoing acute kidney injury. This ratio
will assess the quantity of urinary protein resulting from preexisting diabetic
nephropathy.
Lisinopril may be restarted after blood urea
nitrogen and serum creatinine levels return to
baseline or stabilize (with periodic monitoring
of these and, serum potassium level).
Restarting lisinopril will be especially important for slowing progression of dia-
betic nephropathy if the random urinary protein-creatinine ratio is > 0.5.
Consider nephrology follow-up. Nephrology follow-up will be important if the urinary protein-creatinine ratio
is > 0.5 or blood urea nitrogen and serum creatinine levels fail to return to
baseline.
Patient education: We informed the patient and his caregiver that ibuprofen and
similar over-the-counter nonsteroidal anti-inflammatory drugs should be avoided
to decrease risk of recurrence of kidney damage and other complications such as
gastrointestinal bleeding.
on September 3, 2024. For personal use only. All other uses require permission.www.ccjm.orgDownloaded from
CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 82 • NUMBER 1 JANUARY 2015
17
VENKAT
creating a shorter document that contributes
adequately to patient care, provides greater edu-
cational value, and may promote cost-effective
medical practice. Also, not requiring redundant
documentation may reduce or even eliminate
undesirable copying and pasting.
Accountable-care organizations are an
important part of the Affordable Care Act,
16
which went into effect in 2014. Many organi-
zations had already come into existence in the
United States before the act became effective,
and their numbers and the number of patients
covered by them are projected to grow enor-
mously over the next few years.
17
Since the accountable-care organization
model will rely heavily on capitated reim-
bursement to contain costs, these organiza-
tions are likely to scrutinize and curtail the
use of consultations. I believe that a shorter
consultation note—yet one that is more
useful for patient care, education, and cost-
containment—is more likely to pass such
scrutiny, especially if it decreases time spent
on documentation. Furthermore, unlike the
fee-for-service model, in a capitated-payment
system it may not be necessary to lengthen
consultation documentation just to ensure
adequate reimbursement.
■
■ REFERENCES
1. Department of Health and Human Services; Office of Inspector Gen-
eral. Consultations in Medicare: coding and reimbursement. http://oig.
hhs.gov/oei/reports/oei-09-02-00030.pdf. Accessed November 24, 2014.
2. Hartzband P, Groopman J. Off the record—avoiding the pitfalls of
going electronic. N Engl J Med 2008; 358:1656–1658.
3. O’Malley AS, Grossman JM, Cohen GR, Kemper NM, Pham HH. Are
electronic medical records helpful for care coordination? Experiences
of physician practices. J Gen Intern Med 2010; 25:177–185.
4. The Center for Public Integrity; Schulte F. Electronic medical
records probed for over-billing. Critics question credibility of
federal panel charged with investigating. www.publicintegrity.
org/2013/02/14/12208/electronic-medical-records-probed-over-billing.
Accessed November 24, 2014.
5. Li B. Cracking the codes: do electronic medical records facilitate
hospital revenue enhancement? www.kellogg.northwestern.edu/
faculty/b-li/JMP.pdf. Accessed November 24, 2014.
6. Hirschtick RE. A piece of my mind. Copy-and-paste. JAMA 2006;
295:2335–2336.
7. Thielke S, Hammond K, Helbig S. Copying and pasting of examina-
tions within the electronic medical record. Int J Med Inform 2007;
76(suppl 1):S122–S128.
8. Hanlon JT. The electronic medical record: diving into a shallow pool?
Cleve Clin J Med 2010; 77:408–411.
9. Fitzgerald FT. The emperor’s new clothes. Ann Intern Med 2012;
156:396–397.
10. Bernat JL. Ethical and quality pitfalls in electronic health records.
Neurology 2013; 80:1057–1061.
11. Thornton JD, Schold JD, Venkateshaiah L, Lander B. Prevalence of
copied information by attendings and residents in critical care prog-
ress notes. Crit Care Med 2013; 41:382–388.
12. Foote RS. The challenge to the medical record. JAMA Intern Med
2013; 173:1171–1172.
13. Tamburello LM. The road to EMR noncompliance and fraud is paved
with cut and paste. MD Advis 2013; 6:24–30.
14. Goldman L, Lee T, Rudd P. Ten commandments for effective consulta-
tions. Arch Intern Med 1983; 143:1753–1755.
15. Salerno SM, Hurst FP, Halvorson S, Mercado DL. Principles of effec-
tive consultation: an update for the 21st-century consultant. Arch
Intern Med 2007; 167:271–275.
16. Longworth DL. Accountable care organizations, the patient-centered
medical home, and health care reform: what does it all mean? Cleve
Clin J Med 2011; 78:571–582.
17. Meyer H. Many accountable care organizations are now up and run-
ning, if not off to the races. Health Aff (Millwood) 2012; 31:2363–2367.
ADDRESS: K. K. Venkat, MD, Senior Staff Physician, Division of Nephrol-
ogy and Hypertension, Henry Ford Hospital, 2799 West Grand Boulevard,
Detroit, MI 48202; e-mail: [email protected]
on September 3, 2024. For personal use only. All other uses require permission.www.ccjm.orgDownloaded from
