"These findings raise the possibility that some documentation may not accurately represent physician actions." Interesting study, unsurprising (to me, at least) conclusion.https://twitter.com/JAMANetworkOpen/status/1175213052104454144 …
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Replying to @AdamRodmanMD
Documentation based reimbursement schemes normalize lying in healthcare. Probably not great for our profession or for our patients.
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Replying to @Cortes_Penfield @AdamRodmanMD
also fear of lawsuits- “if you didn’t document it, it didn’t happen” incentivizes extra aggressive documentation
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Replying to @grepmeded @Cortes_Penfield
Though I have to imagine an inaccurate templated exam hurts more than no exam (such as documenting intact cranial nerves in a patient who has had a stroke).
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Yes but fear-driven actions don't have to be effective to be widespread. I think more than fear of lawsuits is fear of being hassled by documentation admin. The arbitrary cms/insurance documentation requirements are the primary driver of these problems.
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Replying to @nick_gowen @AdamRodmanMD and
At my institution I'm required to ask residents to place addendums to h an ps that don't have "2 in 9" PE coding criteria. It hurts my soul every time, and makes me wonder how our system got so dumb.
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recently got a call asking me to justify in my note “patient needs to be hospitalized because___”. I guess problem list with hypotension, GIB, thrombocytopenia, and nephro saying may need pressors to tolerate HD wasn’t clear enough? addended my note to avoid a callback
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