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Monday, February 1, 2010

Documentation: another reason for radical tort reform

In medicine we always seem to use a word with many syllables where a couple of words that people can actually understand would do. Thus the word "documentation". In the practice of medicine, since I have been practicing it, we spend lots of time writing stuff down.  The amount of this writing or typing or dictating or computer point and clicking that we do has gradually increased, and is now eating up the time that we could use to do other important things, like take care of patients, for instance.

In my own practice I spend over half of my time creating some sort of record of what is going on with my patients' care.  Most of it is necessary, and if I were to reduce the time that I spent in documentation, it would be by streamlining the process, maybe by using a better computer system. Most of the words on paper or words on a screen are valid communication, though the detail in which I keep my records is primarily to satisfy insurance companies and the legal system should I be unlucky enough to be sued.

In the hospitals and the nursing homes, though, the situation has become much more dire.  One nurse I spoke to today said that she spends at least 4 hours of a 12 hour day record keeping, and of that she thinks that probably nobody reads any but a tiny fraction of it.  The nurses I work with in the intensive care unit say that anywhere from half to three quarters of their time is spent in documentation, and maybe 20% of that is ever useful. "The only one who is ever going to read this stuff is the lawyers," said one of them. In nursing homes the situation is the same, and with the ratios of staff to patients that nursing homes have, this results in hurried and inattentive care and unhappy harried staff.

I would propose that in reforming the tort system and insurance systems the whole system of documentation be revamped.  This would require the involvement of nurses, physicians and administrators to determine exactly what parts of the documentation we do actually benefit the process of taking care of patients.  Sometimes writing can be part of remembering, in the case of complex work routines. It would also require a cooperative interaction with whatever legal organization would deal with medical error and malpractice, since this will not entirely go away. If malpractice law is reformed in the way it should be, to make it a vehicle for compensation and quality improvement, we will need to have some way of tracing what happens in situations of medical injury. We will need to be able to look at the processes that lead to errors so we can change systems to work more efficiently.

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