Documentation Disillusionment
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THE LEARNER'S VOICE
Documentation Disillusionment Nat Mulkey 1 Received: 2 August 2020 / Accepted: 30 September 2020 # Academic Psychiatry 2020
Writing a patient’s psychiatric note is truly a challenge, and I love it. Different from other specialties, the psychiatric note requires more subjective impressions from the author, with less pre-formed objective data (e.g., labs, test results) to rely on. High-quality patient documentation, including accurate, unbiased details of their medical and psychiatric history, goes far in helping to provide patients with cohesive care. It is not surprising that “documentation and communication” is a core clinical skill emphasized by undergraduate medical educators. The learning objectives for medical student psychiatric documentation include writing an accurate history, exam, daily progress updates, and overall diagnostic impression [1]. At the beginning of my medical training, with these objectives in mind, I thought all patient documentation would be a perfectly crafted retelling of subjective data, leading to an accurate diagnosis. Entering the clinical world as a medical student, I began to see how this ideal of clinical documentation stacked up against reality. When I began to utilize patient charts, I came across a frustrating phenomenon. While reviewing background information for one of my patients, their chart stated they had bipolar disorder, anxiety, and depression. Though it was possible that this patient had a complex psychiatric history, this seemed inaccurate even with my basic understanding of diagnostic criteria. How could one individual have both bipolar disorder and unipolar depression? It turned out that there were many patient charts containing an array of psychiatric diagnoses that were not easily substantiated. The reason for this soon became clear to me, not from any formal didactic but by accident. While putting the finishing touches on one of my notes, I concluded that a patient likely had some form of “altered mental status,” yet I did not feel I could give any more specifics without compromising accuracy. My preceptor informed me that I would need to change the diagnosis to “delirium”
* Nat Mulkey [email protected] 1
Boston University Medical School, Boston, MA, USA
because “altered mental status” was not a billable diagnosis. I thought to myself: what is a billable diagnosis? When I got home, I started to investigate this question. Apparently, centralized diagnostic classification systems have been around since the late nineteenth century. The most recent iteration is the ICD-10 coding system. Using these codes, and using them well, is how physicians and healthcare systems get reimbursed. The ICD-10 provides many advantages including a uniform system of diagnosis and data that can be used for research [2]. However, this system has also been criticized for its collateral consequences, including the effects of directly tying these codes to physician pay. Critics argue that the ICD-10 and prior coding forms have led to incomplete and inaccurate informat
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