My course for attendings has been CME APPROVED for 3.5 hours! The pre-sale will end in 5 days when the course goes LIVE. Get it now for 197 $148!

I will be sending an email 24 hours before the sale ends (on midnight CST on May 2nd).

Hold up!

Following the new 2023 E/M updates might put you in violation of your hospital's bylaws and policies. Specifically, NOT documenting the review of systems, past medical / family / social histories. I suspect many are inadvertently guilty of this - I was! Many hospital bylaws likely haven't been updated since 2023 and were written during the "standard" of the 1995 / 1997 E/M guidelines. So, do bylaws need to be changed? Probably so but that’s up to your hospital’s administration. Check out my post / discussion in the comments about this topic on LinkedIn.

Is clinical documentation so removed from its original purpose that attempting to restore it is a lost cause?

How do we inspire bedside providers to focus on clinical documentation?

We create a movement of Clinical Documentation Stewardship.

The Current State of Documentation

1. We spend >50% of our time in front of computers. Much of that time is reading and writing notes. That time (along with many problems with EMR’s) is contributing to burnout which results in physician shortages and medical errors. Patients are suffering.

2. Copy / paste is a useful but dangerous tool. It’s like fire - it can cook your food or burn you.

3. Formal education in medical training is largely non-existent. It is typically done piecemeal by people who don’t truly understand the productivity pressures their residents will face, nor truly understand professional and hospital billing requirements.

4. U.S. notes are 4x longer compared to non-U.S. notes. A major contributor to this is the PERCEIVED requirements of billing.

What I believe

1. Like it or not, documentation is a major part of our profession and these problems are reaching critical mass. Hospitals, residencies and med schools have a duty to address them.

2. Every step of a patient interaction is a chance to be systematic and organized. Documentation is a vital part of that interaction.

3. Efficiency is not a dirty word. We should embrace it to increase quality while removing waste - particularly wasted wordiness.

4. Notes, like antibiotics, have far-reaching negative unintended consequences when used improperly. We should recognize this and take responsibility for everything in our notes and their impacts on our patients, our colleagues, ourselves and our hospitals - a concept I call Clinical Documentation Stewardship.

Are UM and CDI professionals inadvertently contributing to these problems?

I believe so.

Many UM and CDI professionals don’t realize providers aren’t getting documentation education from anyone else. We ARE the hospital’s documentation experts. To make matters worse, documentation and template expectations are often set by IT / EMR professionals (who certainly don’t understand these complexities) during provider onboarding.

We should embrace this responsibility. But are we too far gone? Is it a lost cause?

A new hope, from twitter.

Though I’m known now as “The Doctor of Documentation,” my beginnings were not so clear. Yes, my hope was to use twitter (X) to educate on CDI. But there was a problem.

CDI is not sexy.

And I thought no one cared about documentation. How could I actually get engagement and followers?

In the content creator world, they say “make noise and listen for a signal.” Meaning, write on a bunch of stuff and see what gets engagement. I assumed I would have to write on other topics, get people to follow me, and I’d sprinkle in the CDI topics here and there.

After 2 months I had gained about 200 followers. Nothing was really catching on. So, I finally wrote my first thread on documentation.

In the first 8 hours I had… 4 likes. And a single comment. It was confirmation of my suspicion. No one cared about documentation.

But over the following 48 hours the thread went viral getting >5,000 likes, gaining me 1500 new followers, and ultimately seen by 1 MILLION people.

1,000,000 people!

I had my signal.

But it wasn’t just a signal for me, it’s hope for all documentation experts out there.

People DO care and they’re hungry…no…desperate to learn more because they KNOW that documentation impacts their day to day lives. And they know it’s a problem.

But, we can’t just talk in theories. We must give them practical, actionable tips that they can immediately implement, for free, regardless of their EMR.

And that is the goal of my newsletters, social media content, and video courses.

I’m creating a new generation of documentation stewards. Will you join me?

This was an excerpt from my recent talk, “From Twitter with a New Hope, Creating Stewards of Documentation,” given at the National Physician Advisor Conference in Coronado, CA put on by the American College of Physician Advisors. Thanks to Dr. Erica Remer for encouraging me to talk. Thanks to all of those who came to the talk and gave me such wonderful feedback. Most of all thanks to you, my subscribers, for being with me on this journey.

When you’re ready, there are two ways I can help you:

1. Check out The Practical Guide to Attending Documentation. Available for $148 (a $49 PRE-sale discount) but not currently published as I finalize details. It’s a step-by-step guide using short videos so you can:

• Reduce downgrades (which cost you money) and be 100% confident about billing

• Write shorter, more effective notes

• Prevent lawsuits

• Reduce medical errors

2. Check out The Resident Guide to Clinical Documentation. The course that helps you:

• Prepare for real-world productivity pressures by optimizing your notes for efficiency.

• Gain the confidence to write shorter yet more effective notes.

• Impress your attendings and improve your evaluations.

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