Good morning everyone
Hope everyone is doing well on this beautiful sunny morning.
I have been becoming more disenchanted by the structure of the surgical critical care notes in my institution. In fact, as we all know, "EMR" has been sited as one of the contributing factors to physicians' burnout in multiple studies. Covering an ICU service week is hectic and mentally draining at times. Nonetheless, it also offers a rewarding experience, both from an educational and intellectual standpoint.
However, when the time comes (usually after completing teaching rounds) to write notes, I find it utterly frustrating. Not only do you have to edit the residents notes (which often times have outdated, incomplete or inaccurate information), but you have to navigate EMR, provide a billable attestation, all while attempting to include medically pertinent information that other colleagues can refer to when they review the chart.
We are in the process of revamping our notes in an attempt to provide an example of what a "proper ICU note" should look like. In doing so, we are hoping to achieve two major goals:
1. providing an intelligent and properly worded note
2. including all the important "buzz words" that are expected to be in an ICU note that provides maximum billing
We have identified a number of issues that we are working on. Certainly meeting with IT, representative from our EMR gurus, as well as the coding and billing departments in our hospital is part of our plan/solution.
Does anyone care to share their wisdom if they have experienced this in the past? How did you overcome this problem in your institution?
Does anyone have a good reference for what you would call the "perfect ICU note"?
Many thanks and have a great weekend...
Osama Elsawy, DO FACS
Saint Joseph's University Medical Center
------------------------------
Osama Elsawy, DO FACS
Medical Director of SICU
Trauma and Acute Care Surgery
Saint Joseph's University Medical Center
Paterson, NJ
------------------------------