It’s 6:30am on the general surgical ward. Three residents are preparing for the round. We’re looking up results, printing lists, and creating ward round templates. All is calm.
Then, the registrars arrive.
The three of us all but chase them around the ward. Two of us leapfrog each other to take notes for every second patient. The third resident takes down the jobs. We are struggling to keep up.
I manoeuvre the mobile computer into the room as quickly as I can, but the history has already begun. I try to take down as much as I can hear. The registrar presses on the patient’s abdomen without comment. As we leave the room they say “NBM, insert NG on free drainage, six minibags, IV PPI.”
We don’t have time to finish the notes on the round, so we save drafts and come back to them later. As we’re grappling to finish them, WhatsApp messages are flashing on our phone screens. The registrars want us in clinic. It’s overbooked again: there are eighty patients in the morning clinic alone. We finish the notes as quickly as we can and race upstairs to help.
This happens almost every day for ten weeks.
The Situation
As a medical student, I was warned about the paperwork burden of intern year. I imagined myself drowning under a sea of notes, request forms and discharge summaries, and the reality was not far off.
In the current medical hierarchy, the most junior members of the team are primarily responsible for maintaining the patient record. Does this reflect the low value placed on documentation by the medical profession? Or are junior doctors simply the best at clinical documentation?
The data would suggest that it isn’t the latter.
In my auditing experience, public hospitals, in which juniors are doing the bulk of the documentation, show a similar lack of documentation quality to the private system.
Why are the tech savvy younger generation of medics, supposedly extensively educated on communication and the medicolegal importance of the patient record, not any better at documentation than their bosses?
The Problems
Junior doctors often don’t have the clinical experience to understand what their seniors imply but do not specify.
When you’re learning so much so quickly, it’s easy to forget how far you’ve come. When I was a senior house officer, it would boggle my mind that an intern didn’t know something I considered so fundamental to the job. Looking back, of course, I hadn’t known it when I was an intern either and had learned it gradually through experience. It’s understandable that registrars, especially senior regs, make lightening fire assessments and assume that everyone in the room is on the same page.
In fact, they’re often not even reading the same book.
On a general surgical ward round when I was an intern, a registrar clinically assessed a patient without comment, said “upgrade diet to free fluids,” and strode to the next room. I had no idea what was happening but was expected to succinctly and accurately document the review, assessment, and plan for that patient.
What was going through the registrar’s head, and what they assumed I also understood, was the following. “Given the patient’s reducing pain and improving observations, their pancreatitis is clinically improving. They can therefore trial an upgraded diet, and we will assess again tomorrow. If during the day they get worsening pain, the nurses can step them back to clear fluids.”
Yet as I, the person documenting, didn’t understand, the notes didn’t reflect that clinical truth.
Junior doctors are often not empowered to ask questions.
This is related to the point above and varies considerably depending on the seniors. I have experienced both ends of the spectrum.
Once, when reviewing an unwell patient on the post-take ward round, a medical consultant dictated to me exactly what they wanted me to write, explained the medicine behind it as they went, and brainstormed out loud. Not only did those notes reflect the clinical truth and clearly communicate the plan, but I learnt more from that one review than I had in weeks.
When working with a different team, I told the senior registrar that I often didn’t understand the indication for the plan on the ward round and asked if I could be given a bit more explanation as we were going. I was told that there “wasn’t time” on the round to discuss the rationale, and that we could discuss it afterwards. Needless to say, this never happened.
Therefore, the notes I wrote had no indication for treatment, the diagnosis couldn’t be coded, and the hospital lost out on well-deserved reimbursement.
Junior doctors often don’t want to “hang their hat” on a diagnosis.
When you’re inexperienced, it’s completely reasonable that, sometimes, you don’t know the diagnosis. If you’re keeping patients safe, considering life threatening conditions to be excluded, and escalating when appropriate, it’s okay that you don’t always have the answer. However, doctors are a perfectionistic bunch, and there’s sometimes a negative attitude and an intense fear of being wrong.
What better way to be right than to keep your diagnosis broad? If you say chest infection, you’ll definitely be right. Specify lobar pneumonia, however, and it turns out to be viral pneumonitis, then you got it wrong. The evidence supports that this is exactly what juniors do, and that specificity improves with experience.
Another contributor is that in the frenzy of clinical learning and practical skills, the nuances of classification learnt in medical school become blurred. It’s easy to forget the difference between Child’s Pugh A, B and C, but still know that the patient has liver cirrhosis.
The downside of all this, of course, is that increased specificity is often associated with a higher complexity score, and therefore, greater funding. Documentation of more specific diagnoses also improves communication and safety.
Junior doctors often have little to no understanding of coding or Activity Based Funding.
My scanty knowledge of this topic when I was working clinically was mainly based on hearsay among the juniors.
We did have a session by the Health Information Manager during our intern week, but it was lost amongst the sheer volume of new information. Given the fact that some talks were about managing diabetes or deteriorating patients, my brain knew what it wanted to hang onto, and it wasn’t coding.
Our hospital tried to improve our documentation by giving us DRG “tick sheets”. After completing the discharge summary, we were meant to tick additional diagnoses that had contributed to the admission. However, consensus was lacking among us as to what counted. Out of genuine ignorance and a desire to improve hospital funding, I enthusiastically ticked all the co-morbidities of my patients, somewhat logically, but incorrectly, thinking that the administration of regular medications meant that these “contributed” to the admission.
Another myth that circulated the hospital was: “write constipation! It gets the hospital seven thousand dollars!” As I was working in an underfunded hospital, I dutifully documented constipation when it was present and felt very pleased with myself about the amount of money I was generating. Of course, I didn’t understand that I needed to be clearly documenting my review and treatment plan to ensure that it met Australian Coding Standard 0002 and could contribute to the patient complexity.
Junior doctors imbibe the attitudes of their seniors.
Sometimes registrars and consultants don’t value documentation and see it as purely an administrative task that falls to the juniors. This attitude is easy to understand. Registrars have served their time as juniors drowning in paperwork. It’s reasonable that when they step up into a more clinical role, they want to touch the notes as little as possible. Older doctors might have come from an earlier era of significantly less documentation and see time spent writing as detracting from clinical work.
This can mean that, not only do junior doctors copy this negative attitude towards clinical documentation, they are also not given the information they need by the seniors to complete the record appropriately.
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So we’ve seen the tricky situation that junior doctors are in, caught between the expectations and time pressures of their seniors and the need to appropriately document.
In the next installment of this article, we will look at the effects of poor documentation on junior doctors themselves. And we’ll ask the question: how can CDSs work with junior doctors to revolutionise documentation culture?
Dr Felicity Sinclair-Ford is a medical doctor with a diverse range of educational experiences. As well as studying languages and the humanities at a tertiary level, Felicity has worked as a resident medical officer in hospitals in Queensland, New South Wales and the Northern Territory. Her time in the clinical space prompted her interest in patient safety as it relates to clinical documentation.
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