Systems versus problems based notes.

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Systems-based versus problems-based.

Is one better than the other?

Well… I look at documentation through its four purposes:

1. Synthesizing

2. Communicating

3. Legal protection

4. Billing

When you do that, one is clearly superior.

Now before I get a bunch of angry ICU physicians in my inbox, I’ll say I fully understand the benefits of the systems-based approach for critically ill patients. They’re complex and it’s an important framework to think of the patient from “top to bottom.” I’ve discussed with some who prefer a systems-based format and we all agree: a pure systems-based note with no mention of problems is unacceptable. Unfortunately, I see that format often. The ideal is for problems to be listed under the systems. So, if I can convince intensivists to do that, it would be a huge win.

Let’s dig in and look at this topic through the four purposes.

Synthesizing

The act of naming a problem (versus putting a plan under a system) is a moment to think, "What am I treating?" This is a moment to consider alternative diagnoses as well. Otherwise, you may give IV Lasix, antibiotics, etc., without truly thinking about the actual underlying diagnoses.

Additionally, the act of writing out why you think it is that diagnosis (and why it’s not an alternative diagnosis) helps you synthesize. We allow ourselves certain graces and gaps in our thinking without realizing it, but when you put “pen to paper,” you must lead Point A to Point B to Point C. It’s a crucial step in verifying your own thoughts.

Doctors “think in ink” more than we realize. Some need to do it more explicitly. Others have admitted they thought something was wrong with them because they get so much benefit out of thinking while writing notes. It is of course 100% normal and encouraged.

While one small study did not show a difference in delayed diagnosis between systems-based and problems-based notes, there are other reasons to document the problems you’re treating and considering:

Communicating

Your note is a communication tool.

People want to know the diagnosis you’re treating - not only other doctors, but also nurses, pharmacists, etc.

If you have:

but never call it a stroke or acute CVA, nurses may not know to do their stroke protocols. Also, others new on the case will have to “reinvent the wheel,” figuring out what’s actually going on rather than knowing immediately from your note. This, at best, wastes their time and, at worst, could cause a medical error as we often don’t have time to search the chart in its entirety.

I know this by experience.

It may seem trivial considering one problem, but it becomes deeply problematic with 10+ problems for 20+ patients. You’ve already done the mental work. Help your colleagues by spelling it out.

Another example:

Remember, your note communicates to the future you. And with our patients becoming increasingly complex, it's easy to get them mixed up. If your note is written as above, you, yourself, may forget that the patient has an LVEF of 25%. This holds true for partners you may hand off to as well.

This would be better.

One last example, if you’re a neurointensivist and write:

It’s unclear you’re aware of an additional reason the patient is on apixaban, which is not only for atrial fibrillation but also for a recent acute pulmonary embolism. But if you have the actual problems listed out such as:

then you’re:

1. More likely to consider (synthesize) when it’s best to restart anticoagulation because you know it can’t be held indefinitely because…

2. The hospitalist you’re stepping down to is going to need to know when it can be restarted (communicate). If not, they’ll have to call and ask your thoughts which, again, is at best wasting both of your time, or at worst, could lead to a medical error.

3. This documenting that you’re aware of the PE and that you’ve considered it in the context of holding anticoagulation leads us to our next point.

Legal Protection

Explaining the diagnoses that you treated and considered is not only helpful for helping you think, but it goes a long way in helping your case against negligence (aka, you didn’t ignore certain considerations such as the consequences of holding anticoagulation with a recent pulmonary embolism).

If you never attempt to give a diagnosis or explain why you did or did not treat certain differentials, your legal risk increases.

Remember, your documentation would also help refresh your memory in the case of litigation (which might be years later).

Finally, when your note is an ideal communication tool to the rest of the care team (as explained above), it reduces the likelihood of medical errors - keeping the lawyers away in the first place.

Billing

I once spoke to an intensivist who was manually adding each individual problem to her professional billing charges. Yet, her notes were systems-based and therefore didn’t mention any of those problems. Her charges likely wouldn’t survive an audit because her note didn’t have any overt MEAT criteria for those problems (Monitor, Evaluate, Assess, Treat), which is required.

For hospital billing, this is often based on the diagnosis responsible for the admission. By never naming a diagnosis, you’re sabotaging yourself and your hospital. All while setting yourself up to get inundated with queries.

We’re slowly moving towards value-based care. These insurance models and many metrics are “risk adjusted.” What does that mean? Well, for example, RAMI (the observed to expected mortality ratio) is not simply, “How many patients did you care for and how many of them died?” It instead analyzes each patient that died and their unique risk of dying. That unique risk is based on how sick that patient was, and that “sickness” is determined by all of their problems and comorbidities. Those problems and comorbidities are based on your documentation during that encounter (so “see rest of chart for other problems” doesn’t help). Therefore, the more complete your documentation is in naming specific problems, the better your metrics will be.

So, hopefully it’s clear that using problems-based (rather than a pure systems-based) is better for you, your patients, your colleagues and your hospital. For intensivists that rely on the systems-based approach, I’d consider it a win if I can at least convince you to name the problems under the systems rather than the pure “system + plan” approach I see so often.

That’s all for now. I hope that was helpful.

Please feel free to reach out and ask questions as they help inspire future issues!

Cheers,

Robert

Special thanks to my editor, Laura Samson, RN, BSN, CCDS.

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