What's the objective of the objective section?

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The objective section is for vitals, physical exam, labs, radiology findings, etc.

But EMR’s and the old 1997 billing rules resulted in the habitual practice of auto-populating labs and radiology reports.

Should we be doing this?

My obvious teaching point is this: Don’t document something that you didn’t actually do.

People roll their eyes when they hear this and think, “Of course I wouldn’t do that.”

But then they auto-populate their physical exam (which I’ve written on previously) labs and radiology findings into their note - which is “proof” that they’ve “reviewed it.”

Let’s look at this issue through the four uses of notes:

1. Do they help you think through the patient’s case?

Of course not. Nothing that occurs automatically will.

2. Do they help you communicate?

With the exception of faxed notes to outside hospitals, 99.9% of people are going to the EMR for that information.

Plus, anyone who has received outside hospital records knows progress notes are typically buried in all the labs, radiology reports, nursing notes, etc. So, no.

3. Do they help you legally?

NO.

In fact, they do the OPPOSITE.

For legal purposes, you’ve “reviewed” everything in your note. This is largely why this practice started - to get credit for “reviewing” for billing (which no longer counts).

So, that finding you missed because it was buried in the body of the report but didn’t make it to the final impression but was actually clinically significant but by including it in your note you legally “reviewed it” - yeah you’re responsible for that.

And that incidental finding that you forgot to do something about? - Yup if it’s in your note you have no defense that you didn’t see it.

That fact terrifies me and should be enough to make anyone stop this practice.

4. Do they help you with billing?

The 2023 E/M billing updates added language such as “unique” to reviewing labs and tests. This means you can no longer claim credit for simply saying “I reviewed the labs.” You must be specific.

Additionally, every professional billing auditor and consultant I’ve interacted with say they’re looking for how each test is specific to THAT patient THAT day and how YOU interpret it.

So first of all, you’re not getting credit for pulling in that SAME chest xray EVERY day.

Second, you’re not getting credit for simply including a lab such as a Creatinine of 1.5. You must say how it relates to the patient that day.

To make sure I’m clear, I have a dot phrase that inserts “I reviewed” then I free text / dictate my interpretations. So, it looks something like this:

Someone did mention a use that made me pause…

They auto-populate labs so when they’re inserting their review / interpretation of the labs, they do not have to go back to the labs tab…they can just glance right above.

I’m all about efficiency and that’s a fair argument if EMR’s could pull in labs concisely in the “fishbone” format…

But this usually pulls in too much information and leads to note bloat and information overload…which is a growing problem.

And you still have the legal concerns.

In my course, I mentioned two ways of approaching this. The ideal way, I said, was to “check these boxes” naturally in the A&P…which we probably do often.

That’s still the ideal, but I’ve found myself reviewing my A&P to ensure I got all my MDM points - which was costing me too much time.

So, I’ve ultimately found it more efficient to include my brief statements, such as the example above, in the objective section before moving to my A&P.

Will there be a bit of repetition? Probably. But, my statements are short so don’t contribute to bloat.

And I have complete freedom in my A&P without inserting “billing language.”

Finally, I’ve actually had a few instances where I’ve noticed findings I had missed earlier…so reviewing for billing purposes has actually helped me take better care of the patient (Billing helping patient care…bet you’ve never heard that one before 😆).

Some CDI professionals may argue pulling in these reports allows them to query for some conditions. But, sorry y’all, I’m taking the anti-note-bloat and legal side of things for this one.

So, PLEASE stop auto-populating labs and radiology reports for the sake of you, your patients, and your colleagues!

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

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