#JHMChat Transcript

Healthcare social media transcript of the #JHMChat hashtag.
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See #JHMChat Influencers/Analytics.

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Society of Hospital Medicine @SocietyHospMed
RT @WayneLiangMD: Gearing up for tonight’s @JHospMedicine #JHMChat “what makes a good clinical note” HT @MattSakumoto
Society of Hospital Medicine @SocietyHospMed
⏰ 🔟 minutes until this month’s #JHMChat! 🩺 Tonight’s facilitator and guests: @LannaFelde as @JHospMedicine, @blairgolden, @medrants, and @andrewolsonmd. Don’t forget to use #JHMChat in all tweets! Need a refresher on how to join? 👀👇 https://t.co/ivHhIPERG8 https://t.co/asOx4wJcHe
Journal of Hospital Medicine @JHospMedicine
The countdown begins!⌛ Just 🖐️ minutes until we start our live #JHMChat: EMR Documentation 📝 💻. What makes a good note❓ We know you got opinions on this one and we're all 👂. Our special guests are waiting in the wings: 👩‍⚕️@blairgolden 👨‍⚕️@medrants 👨‍⚕️@andrewolsonmd
Gopi Astik @gopiastik
Stretching my thumbs and getting ready for #JHMChat @JHospMedicine https://t.co/bL4BoVxQsk
Society of Hospital Medicine @SocietyHospMed
@gopiastik @JHospMedicine Right there with you! #JHMChat https://t.co/FaDOFhiCjr
Michelle Brooks, MD @michellebr00ks
Pretty excited for this chat! Unfortunately, #myJHMmug is in the moving van, but hopefully we'll be reunited soon! #JHMChat
Journal of Hospital Medicine @JHospMedicine
Welcome to #JHMChat. I'm so glad you're here! I'm @LannaFelde and I am so excited to be your moderator this evening🎙️🤩 💺 Get comfortable 👍 Get your thumbs ready 🙋 Then introduce yourself
Anika Kumar, MD (she/her) @freckledpedidoc
@gopiastik @JHospMedicine Eager #JHMChat Beavers!! https://t.co/zcxz4mxB2k
Society of Hospital Medicine @SocietyHospMed
🏥 Welcome to this month’s #JHMChat. We’re excited for a great conversation! 🔥 📢 Use #JHMChat on all replies. 📢 Introduce yourself and where you’re from. 📢 Engage with the prompts and each other. 📢 Refresh the latest tweets with the hashtag to stay up to date.
Gopi Astik @gopiastik
@JHospMedicine @LannaFelde Hi! I’m Gopi - academic Hospitalist in Chicago. I’m also a Clinical Documentation medical director so joining ##JHMChat with that hat on tonight.
Dhruv Srinivasachar MD (he/el/ele.) @TheRealDSrini
@JHospMedicine @LannaFelde Yay my reminder worked! #MedPeds PGY1 at @WMUMedicine here! #JHMChat
Journal of Hospital Medicine @JHospMedicine
@gopiastik @LannaFelde #JHMChat welcome Gopi!
Journal of Hospital Medicine @JHospMedicine
1️⃣ If it's your first time, welcome! 🕘 If you're a regular, welcome back! 👀 If you're a lurker, happy lurking! #️⃣ Be sure to include #JHMChat in all your tweets so they will appear on #JHMChat feed Still not sure how this works? 👇 👇 👇 👇 https://t.co/6MIOcph027
Anika Kumar, MD (she/her) @freckledpedidoc
@JHospMedicine @LannaFelde Hello 👋. Anika Kumar, Pediatric Hospitalist in Cleveland!! Lookin forward to discussing documentation... #JHMChat
Yichi Zhang (张一弛) @YichiZzzzz
@JHospMedicine @LannaFelde Hey again everyone, lots of familiar faces! My name is Yichi, 3rd-year student and 3rd time at #JHMChat!
Society of Hospital Medicine @SocietyHospMed
RT @JHospMedicine: 1️⃣ If it's your first time, welcome! 🕘 If you're a regular, welcome back! 👀 If you're a lurker, happy lurking! #️⃣ Be sure to include #JHMChat in all your tweets so they will appear on #JHMChat feed Still not sure how this works? 👇 👇 👇 👇 https://t.co/6MIOcph027
Journal of Hospital Medicine @JHospMedicine
@TheRealDSrini @LannaFelde @WMUMedicine Woo! Welcome back Dhruv #JHMChat
Matthew George, MD @MatthewGeorgeMD
Joining #jhmchat tonight
Michelle Brooks, MD @michellebr00ks
Hi - Michelle Brooks - just moved to San Antonio, TX! Currently orienting to my new job as Deputy Associate Chief of Staff for Education at the San Antonio VA (although not today, because apparently it was a holiday?)! #JHMChat
Ndidi Unaka MD, MEd @NdidiUnaka
@JHospMedicine @LannaFelde Hi, I'm Ndidi peds hospitalist in Cincinnati. Excited for this #JHMChat
Society of Hospital Medicine @SocietyHospMed
@TheRealDSrini @JHospMedicine @LannaFelde @WMUMedicine Welcome! #JHMChat
Journal of Hospital Medicine @JHospMedicine
@YichiZTulane @LannaFelde Thanks for joining Yichi #JHMChat
Michelle Brooks, MD @michellebr00ks
RT @JHospMedicine: 1️⃣ If it's your first time, welcome! 🕘 If you're a regular, welcome back! 👀 If you're a lurker, happy lurking! #️⃣ Be sure to include #JHMChat in all your tweets so they will appear on #JHMChat feed Still not sure how this works? 👇 👇 👇 👇 https://t.co/6MIOcph027
Charlie M. Wray, DO, MS @WrayCharles
@JHospMedicine @LannaFelde Charlie Wray, hospitalist in SF Bay, signing on to tonight's #JHMChat Looking forward to tonight's discussion and to learn from @blairgolden @andrewolsonmd & @medrants (aka #UncleBob)
Society of Hospital Medicine @SocietyHospMed
@YichiZTulane @JHospMedicine @LannaFelde Happy you're here! #JHMChat
Blair Golden @blairgolden
@SocietyHospMed Hi all! I'm an adult hospitalist @uwsmph . I'm so excited to be here alongside @andrewolsonmd and @medrants tonight! #JHMChat
Journal of Hospital Medicine @JHospMedicine
@freckledpedidoc @LannaFelde Hi Anika! Thanks for joining #JHMChat
Society of Hospital Medicine @SocietyHospMed
@MatthewGeorgeMD Glad to have you! #JHMChat
Mark Shapiro, MD @ETSshow
@JHospMedicine @LannaFelde Mark Shapiro here. Hospitalist & host of Explore The Space Podcast here! #JHMChat
Andrew Olson, MD @andrewolsonmd
@JHospMedicine Andrew Olson here - Med-Peds hospitalist @umnmedschool - excited to be here with you all. I am the incompetent guest along with the very competent @blairgolden and @medrants ! #JHMChat
Mark Shapiro, MD @ETSshow
@WrayCharles @JHospMedicine @LannaFelde @blairgolden @andrewolsonmd @medrants Evening all! #JHMChat
Robert Centor @medrants
#JHMChat Robert Centor - aka #UncleBob aka @medrants PGY 47
Society of Hospital Medicine @SocietyHospMed
@blairgolden @uwsmph @andrewolsonmd @medrants Welcome! Can't wait for your wisdom #JHMChat
Journal of Hospital Medicine @JHospMedicine
@ETSshow @LannaFelde Great to have you, Mark! #JHMChat
Andrew Olson, MD @andrewolsonmd
@ETSshow @JHospMedicine @LannaFelde There he is! I got a #medpeloton high five from this guy yesterday! #JHMChat
Journal of Hospital Medicine @JHospMedicine
@blairgolden @SocietyHospMed @uwsmph @andrewolsonmd @medrants Thanks so much for being here, Blair! #JHMChat
Andrew Olson, MD @andrewolsonmd
@TheRealDSrini @JHospMedicine @umnmedschool @blairgolden @medrants Great to see you, @TheRealDSrini ! #JHMChat
Mark Shapiro, MD @ETSshow
@andrewolsonmd @JHospMedicine @LannaFelde Hey Pal! #JHMChat
Matt Sakumoto @MattSakumoto
@JHospMedicine @LannaFelde Forgot to add #JHMChat
Temple Ratcliffe, MD, MS-HPEd @templeratcliffe
@JHospMedicine @LannaFelde Temple checking in from San Antonio TX. #JHMChat
Journal of Hospital Medicine @JHospMedicine
#JHMChat Question 1️⃣ : What do you consider the primary purpose of your notes? How do you teach students and residents about best practices in documentation? 📝 https://t.co/rX9pwNYwjy
Cesar Gutierrez @zeesar
@JHospMedicine @LannaFelde #JHMChat
Andrew Olson, MD @andrewolsonmd
@medrants ^^^^ and still showing us how it's done. #JHMChat
Society of Hospital Medicine @SocietyHospMed
@medrants Welcome, Uncle Bob! #JHMChat
Journal of Hospital Medicine @JHospMedicine
@medrants Thanks so much for being here Bob! #JHMChat
Mark Shapiro, MD @ETSshow
@gopiastik @JHospMedicine @LannaFelde Awesome! #JHMChat https://t.co/PrlvDXlYO5
Wayne H. Liang, MD MS FAMIA FAAP @WayneLiangMD
@JHospMedicine @LannaFelde I’m Wayne Liang, a peds #BMT inpatient doc & physician #informatist at @ATLPedsHemOnc @childrensatl @EmoryUniversity #JHMChat
Andrew Olson, MD @andrewolsonmd
@MattSakumoto @JHospMedicine @LannaFelde Great to see you @MattSakumoto ! #JHMChat
Journal of Hospital Medicine @JHospMedicine
@andrewolsonmd @umnmedschool @blairgolden @medrants Thanks so much for being here Andrew! #JHMChat
Society of Hospital Medicine @SocietyHospMed
@WayneLiangMD @JHospMedicine @LannaFelde @ATLPedsHemOnc @childrensatl @EmoryUniversity Welcome to the chat! #JHMChat
Ndidi Unaka MD, MEd @NdidiUnaka
RT @JHospMedicine: #JHMChat Question 1️⃣ : #JHMChat Question 1️⃣ : What do you consider the primary purpose of your notes? How do you teach students and residents about best practices in documentation? 📝 https://t.co/rX9pwNYwjy
Journal of Hospital Medicine @JHospMedicine
Q1 is live!!! #JHMChat https://t.co/97Phe9nN8a
Charlie M. Wray, DO, MS @WrayCharles
@YichiZTulane @JHospMedicine @LannaFelde Glad to have you back, Yichi! Looks like we have a budding hospitalist on our hands...#JHMChat
Society of Hospital Medicine @SocietyHospMed
RT @JHospMedicine: #JHMChat Question 1️⃣ : #JHMChat Question 1️⃣ : What do you consider the primary purpose of your notes? How do you teach students and residents about best practices in documentation? 📝 https://t.co/rX9pwNYwjy
Journal of Hospital Medicine @JHospMedicine
@templeratcliffe @LannaFelde Welcome Temple! #JHMChat
Cesar Gutierrez @zeesar
@JHospMedicine A recipe for others to see regarding patient care and to see the thought process of residents #JHMChat
Robert Centor @medrants
#UncleBob opining on the purpose of notes: Anyone else can read the note and understand what you are doing and why As Weed taught - the assessment and plan is the key to a good note #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@JHospMedicine #JHMChat Q1️⃣: Cant pick 1 primary purpose...but here are 2: 1: to critically think through clinical plan & organize thoughts 2: to communicate that to others most effective way of teaching: 1: feedback! regularly! 2: point out examples of good/not great practices
Andrew Olson, MD @andrewolsonmd
@JHospMedicine A1) This has evolved a bit over my career - but there are many primary purposes (hence the challenge)! But #1 for me is an accurate record of why we are doing what we are doing! But so much more than that too... #JHMChat
Matt Sakumoto @MattSakumoto
@gopiastik @JHospMedicine @LannaFelde I know 🤦‍♂️ I almost had to show myself the door #JHMChat https://t.co/zPrbZIjgCr
Matthew George, MD @MatthewGeorgeMD
◦facility billing, ◦professionals billing ◦medical legal ◦Communication to other providers/ specialists ◦Comunicatiin to patients #JHMChat
Yichi Zhang (张一弛) @YichiZzzzz
@JHospMedicine A1: From a student's perspective, the primary purpose of my notes is to help translate my learned schemas into something more concrete. It helps me practice elaborating my clinical reasoning and is also a great platform for residents/attendings to give regular feedback! #JHMChat
Michelle Brooks, MD @michellebr00ks
@JHospMedicine A1: I think of it as two-fold. One is for communication - for consultants/other docs (and with more transparency, sometimes patients). Two is how we get paid. And all docs who bill for "E/M" services get paid to think. #JHMChat
Society of Hospital Medicine @SocietyHospMed
RT @subhaairan: @JHospMedicine #JHMChat Q1️⃣: Cant pick 1 primary purpose...but here are 2: 1: to critically think through clinical plan & organize thoughts 2: to communicate that to others most effective way of teaching: 1: feedback! regularly! 2: point out examples of good/not great practices
Andrew Olson, MD @andrewolsonmd
@subhaairan @JHospMedicine Love this! I really like the regular feedback and highlighting what was done well. I also try to remember they read my notes/H&Ps so those need to be good examples too... #JHMChat
Society of Hospital Medicine @SocietyHospMed
RT @andrewolsonmd: @JHospMedicine A1) This has evolved a bit over my career - but there are many primary purposes (hence the challenge)! But #1 for me is an accurate record of why we are doing what we are doing! But so much more than that too... #JHMChat
Rebecca Jaffe, MD @RJmdphilly
@JHospMedicine Will pop in and out! Rebecca Jaffe from @TJUHospital in PHL :) #jhmchat
Dhruv Srinivasachar MD (he/el/ele.) @TheRealDSrini
@JHospMedicine @vcuhospitalmed @WMUMedicine #JHMChat (Twitter needs an edit button...)
Blair Golden @blairgolden
@JHospMedicine A1. I use notes to succinctly summarize my current thought process about a patient’s illness trajectory and my to-dos. If I do these tasks well, I'm also able to reflect, stay organized, re-model best practices & effectively communicate with colleagues and patients #JHMChat
Sherine Salib @DrSherineSalib
@JHospMedicine @LannaFelde Hi all! Sherine from Austin, TX- internist & #MedEd enthusiast. Excited to chat with you all tonight. (Currently on service, so EMR documentation is at the forefront of my mind…) #JHMChat
Vinny Arora MD MAPP @FutureDocs
RT @JHospMedicine: #JHMChat Question 1️⃣ : #JHMChat Question 1️⃣ : What do you consider the primary purpose of your notes? How do you teach students and residents about best practices in documentation? 📝 https://t.co/rX9pwNYwjy
Andrew Olson, MD @andrewolsonmd
@MattSakumoto @gopiastik @JHospMedicine @LannaFelde We'll let it slide this time, @MattSakumoto . ..... #JHMChat
Society of Hospital Medicine @SocietyHospMed
@RJmdphilly @JHospMedicine @TJUHospital Welcome! Glad to have you here #JHMChat
Robert Centor @medrants
And the note should be easy to find and digest - uncluttered #JHMChat
Society of Hospital Medicine @SocietyHospMed
@DrSherineSalib @JHospMedicine @LannaFelde Welcome! Thank you for making the time to be here! #JHMChat
Temple Ratcliffe, MD, MS-HPEd @templeratcliffe
A1: Honestly, sitting down to dd each note gives me protected time to think. Writing is thinking. #JHMChat
Gopi Astik @gopiastik
@JHospMedicine A1: Primary purpose of notes is to convey medical information to other members of the care team across sites and encounters. I teach learners both to describe clinical reasoning but also to be specific to capture diagnoses for coding & quality. #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@andrewolsonmd @JHospMedicine Absolutely - that was the other thing I was going to say :) "model good behavior" #JHMChat
Mark Shapiro, MD @ETSshow
@JHospMedicine A1: for me, notes are to organize my thinking, serve as reminder for later in day/next day/off service, 3rd order (weak) communication tool For hospital/organization: billing & publicly reported metrics #JHMChat
Society of Hospital Medicine @SocietyHospMed
RT @gopiastik: @JHospMedicine A1: @JHospMedicine A1: Primary purpose of notes is to convey medical information to other members of the care team across sites and encounters. I teach learners both to describe clinical reasoning but also to be specific to capture diagnoses for coding & quality. #JHMChat
Charlie M. Wray, DO, MS @WrayCharles
@JHospMedicine My 2 cents...To say notes have a singular purpose is probably an oversimplification. For me: (1) Help me process my thoughts, (2) Communicates to colleagues, (3) no billing for me (benefits of VA) #JHMChat
Ndidi Unaka MD, MEd @NdidiUnaka
@JHospMedicine In my mind, notes serve a couple of purposes - the most important being a way to convey a patient's clinical status at a point in time and as an opportunity for a member of the care team to share their thought process and plan. #JHMChat
Andrew Olson, MD @andrewolsonmd
@RJmdphilly @JHospMedicine @TJUHospital Welcome to my #hospitalist leader friend and commiserator! #JHMChat
Robert Centor @medrants
With regards to payment Medicare requirements led to bloated uninformative notes See an editorial by Christine Sinsky in the latest @AnnalsofIM #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@YichiZTulane @JHospMedicine This is a great point. Working through a problem based plan helps solidify frameworks, which guides critical thinking, learning, and helps presentations #JHMChat
Wayne H. Liang, MD MS FAMIA FAAP @WayneLiangMD
@JHospMedicine #JHMChat Q1 primary purpose of #clinicalnotes: Memorializing to myself and communicating to others what happened to the patient, why, and what clinical actions/decisions were taken/made. Also, because I have to write a note.
Journal of Hospital Medicine @JHospMedicine
@DrSherineSalib @LannaFelde Welcome Sherine! Thanks for joining #JHMChat
Charlie M. Wray, DO, MS @WrayCharles
@michellebr00ks @JHospMedicine #2 will soon fall out for you, my new VA colleague Smile. Billing is gone. #JHMChat
Anika Kumar, MD (she/her) @freckledpedidoc
@JHospMedicine A1. I teach Trainees that notes are how we communicate to colleagues & document a patient's story through their hospital stay. Recently, a lot of weight has been placed on using notes for billing. I feel that conflicts with what I teach. #JHMChat
Journal of Hospital Medicine @JHospMedicine
⌛ It's not too late to join this #JHMChat. We're discussing what makes a good note with the one and only @medrants, inspired by @blairgolden and @andrewolsonmd's editorial 👉 https://t.co/JItyqTsBP3 📱 Remember to include #JHMChat in all your responses!
Andrew Olson, MD @andrewolsonmd
@WrayCharles @JHospMedicine Agree with you @WrayCharles - I find that as we use them to document our thoughts >> document data (that exists more cleanly elsewhere) the better we'll do! #JHMChat
Blair Golden @blairgolden
@JHospMedicine A1. Admittedly, I think the function of notes as a billing tool sometimes requires a distinct communication skillset….but would love thoughts from @gopiastik and others about how to synergize these purposes! #JHMChat https://t.co/uVFlc5yXR3
Society of Hospital Medicine @SocietyHospMed
RT @JHospMedicine: ⌛ It's not too late to join this #JHMChat. We're discussing what makes a good note with the one and only @medrants, inspired by @blairgolden and @andrewolsonmd's editorial 👉 https://t.co/JItyqTsBP3 📱 Remember to include #JHMChat in all your responses!
Matt Sakumoto @MattSakumoto
@JHospMedicine A1 In dec priority, TheNote is for: 1) Other care team members (care coordination) 2) The patient (ht @myopennotes) 3) Myself (to remember what I did or was thinking) ... 999) secondary research analysis, billing, medicolegal #JHMChat
Andrew Olson, MD @andrewolsonmd
@ETSshow @JHospMedicine Clearly this sets up a tension, no? #JHMChat
Vinny Arora MD MAPP @FutureDocs
So excited I forgot to index #jhmchat
Robert Centor @medrants
Beautifully stated #JHMChat
Shreya P. Trivedi MD @ShreyaTrivediMD
@medrants YES large blocks of text in notes that will go unread 90% of the time and are painful #JHMChat
Michelle Brooks, MD @michellebr00ks
@JHospMedicine A1: in terms of teaching, agree with the feedback. We switched to a "one note" system, so I had to regularly read and edit student notes that had been read/edited by residents. Great opportunity to discuss making clinical reasoning explicit but succinct. #JHMChat
Journal of Hospital Medicine @JHospMedicine
@blairgolden Dr. Blair with the 🎤 drop! #JHMChat https://t.co/qgrG7dllUr
Charlie M. Wray, DO, MS @WrayCharles
If we were in-person, I'd literally hand @andrewolsonmd the microphone and walk away and just listen to him on this (and lots of other things, as well) #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@medrants could not agree more. everything is structured around the assessment & plan i'm a big proponent of 1) problem based and 2) writing histories by problem as well, instead of chronologic. that way you can fit things into clinical frameworks #JHMChat
Dhruv Srinivasachar MD (he/el/ele.) @TheRealDSrini
@medrants #JHMChat Dr. Larry Weed on the Problem oriented medical record: https://t.co/3W7MPgIPgX
Michelle Brooks, MD @michellebr00ks
RT @andrewolsonmd: @JHospMedicine A1) This has evolved a bit over my career - but there are many primary purposes (hence the challenge)! But #1 for me is an accurate record of why we are doing what we are doing! But so much more than that too... #JHMChat
Charlie M. Wray, DO, MS @WrayCharles
@ETSshow @JHospMedicine I like how you've categorized this, Mark #JHMChat
Andrew Olson, MD @andrewolsonmd
@medrants @AnnalsofIM Agree completely, Bob - they conflated data entry with clinical reasoning documentation... #JHMChat
Robert Centor @medrants
Insightful comment #JHMChat
Andrew Olson, MD @andrewolsonmd
@subhaairan @YichiZTulane @JHospMedicine great wisdom here! #JHMChat
Mark Shapiro, MD @ETSshow
@andrewolsonmd @JHospMedicine I know you well enough to know you don’t ask rhetorical questions Pal Yes it does, one that puts note writer in a bind, causes “note-bloat”, leads to endless queries/questions, causes much cognitive dissonance, does little to improve patient care #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@templeratcliffe 100% agree #JHMChat
Dhruv Srinivasachar MD (he/el/ele.) @TheRealDSrini
@michellebr00ks @JHospMedicine And reasoning starts with the students! Learned a lot of good habits as a student that I use regularly on service! #JHMChat
Vinny Arora MD MAPP @FutureDocs
@WrayCharles @michellebr00ks @JHospMedicine Can I dare to dream #jhmchat
Anika Kumar, MD (she/her) @freckledpedidoc
@WrayCharles @michellebr00ks @JHospMedicine The perks of working at the VA. Unfortunately the VA never has any open positions for Pediatric Hospitalists. 😜 #JHMChat
Wayne H. Liang, MD MS FAMIA FAAP @WayneLiangMD
@JHospMedicine #JHMChat #Q1 teaching trainees how to write a #clinicalnote: I tell them to not just info dump but to write persuasively (with #medicalreasoning) so it’s clear to the reader why they took the clinical actions they took. Presentations also should be persuasive. #medtwitter
Daniel Wolfson @WolfsonD
#JHMChat Great to hear/listen about EMR documentation / maybe I can give a patient perspective. I was one day - surgery on trigger finger.
Matt Sakumoto @MattSakumoto
@ShreyaTrivediMD @medrants ✅ Bullet points or # are your friend, esp in the A/P and Recommendations (Twitter actually has helped train some concise-ness in my daily progress note writing) #JHMChat
S. Trent Rosenbloom @trentrosenbloom
#JHMChat Documentation serves many - too many - purposes. We'd like to think it should be for communication, recording observations and considerations, and education, there are many more stakeholders that value the work we do when writing notes. This now includes engaged patients
Blair Golden @blairgolden
@templeratcliffe I totally agree! Easy for me to say when I am not on service right now but I try to think of my note writing time as a part of my day where I reflect and get organized. #JHMChat
Society of Hospital Medicine @SocietyHospMed
RT @WayneLiangMD: @JHospMedicine #JHMChat #Q1 teaching trainees how to write a #clinicalnote: I tell them to not just info dump but to write persuasively (with #medicalreasoning) so it’s clear to the reader why they took the clinical actions they took. Presentations also should be persuasive. #medtwitter
Andrew Olson, MD @andrewolsonmd
@JHospMedicine Seeing all these great responses makes me wonder - what if we were to "invent" the note in the EHR era? We we wouldn't document much "data" at all since it is elsewhere. We used to do that because it was hard to find, but now it is our thinking/rationale that matters. #JHMChat
Sherine Salib @DrSherineSalib
@JHospMedicine A1. I emphasize to my learners that the medical note is much more than a billing tool. I highlight the importance of the *why* behind documentation. Documentation is: ➡️a communication tool ➡️a powerful clinical reasoning tool ➡️ a #MedEd assessment tool #JHMChat
Journal of Hospital Medicine @JHospMedicine
@MattSakumoto @myopennotes This prioritization is 🔥 #JHMChat
Robert Centor @medrants
@jeffreylinder has advocated for the APSO note put assessment and plans first - then leave the rest of the bloat that no one will ever read #JHMChat
Michelle Brooks, MD @michellebr00ks
@andrewolsonmd @ETSshow @JHospMedicine Huge tension - especially the HPI of some notes where it was obviously clicked through - ends up not telling the story, just clicking enough of the OLDCARTS questions to get the highest billable "history." #JHMChat
Anika Kumar, MD (she/her) @freckledpedidoc
RT @medrants: Beautifully stated #JHMChat
Gopi Astik @gopiastik
I definitely think there’s a way to do both. Early in the stay, definitely write differentials and think out possible diagnoses with corresponding plans. BUT by the end (discharge summary) be able to say the patient has (or likely/probably has) a specific condition. #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@ETSshow @JHospMedicine Curious about your take on communication. I agree it is not the best way for "acute" communication. But beyond the current admission, notes are the only way to know what happened, so i've always thought about them as a very important communication tool #JHMChat
Society of Hospital Medicine @SocietyHospMed
📟 Our #JHMChat is happening NOW with guests @blairgolden, @medrants, and @andrewolsonmd. We’re talking about EHR documentation and crafting a good note. 📝 Don’t miss the best advice and the chance to share your own! 👀 @JHospMedicine @LannaFelde
Society of Hospital Medicine @SocietyHospMed
RT @andrewolsonmd: @JHospMedicine Seeing all these great responses makes me wonder - what if we were to "invent" the note in the EHR era? We we wouldn't document much "data" at all since it is elsewhere. We used to do that because it was hard to find, but now it is our thinking/rationale that matters. #JHMChat
Ndidi Unaka MD, MEd @NdidiUnaka
@JHospMedicine Best practices for trainees - the best notes are concise, and highlight pertinent events/ changes. Delete old info!!! Notes should not be a record of everything that has occurred during a hospitalization. #JHMChat
Andrew Olson, MD @andrewolsonmd
@MattSakumoto @ShreyaTrivediMD @medrants Agree - I've also found that notes have gotten shorter with experience but also relying way more on referencing data elsewhere in the EHR. #JHMChat
Mark Shapiro, MD @ETSshow
@subhaairan @JHospMedicine That’s a good distinction, thank you for adding it #JHMChat
Vinny Arora MD MAPP @FutureDocs
RT @NdidiUnaka: @JHospMedicine Best practices for trainees - the best notes are concise, and highlight pertinent events/ changes. Delete old info!!! Notes should not be a record of everything that has occurred during a hospitalization. #JHMChat
S. Trent Rosenbloom @trentrosenbloom
#JHMChat The multiple uses for the note are fine so long as they contribute to healthcare delivery broadly defined. They are problematic when they lead to burden. #25x5
Robert Centor @medrants
@WrayCharles @JHospMedicine We do have VA in common - my notes can get to the point! #JHMChat
S. Trent Rosenbloom @trentrosenbloom
RT @WayneLiangMD: @JHospMedicine #JHMChat #Q1 teaching trainees how to write a #clinicalnote: I tell them to not just info dump but to write persuasively (with #medicalreasoning) so it’s clear to the reader why they took the clinical actions they took. Presentations also should be persuasive. #medtwitter
Andrew Olson, MD @andrewolsonmd
@subhaairan @ETSshow @JHospMedicine I agree, especially with respect to the discharge summary - this *is* the record of what happened during a stay! #JHMChat
Anika Kumar, MD (she/her) @freckledpedidoc
@ETSshow @andrewolsonmd @JHospMedicine Many of the drawbacks listed also add to the #burnout physicians experience as they deal with EMRs for billing purposes #JHMChat.
Matthew George, MD @MatthewGeorgeMD
My organization is actually trying to leverage emr by building preset problem based charting language for the top 10 “cdi I queried diagnoses” . However I quickly realized there’s already many competing requirements for documentation that make it almost impossible to do #JHMChat
Wayne H. Liang, MD MS FAMIA FAAP @WayneLiangMD
@trentrosenbloom 👆bringing the wisdom #JHMChat
Matt Sakumoto @MattSakumoto
@andrewolsonmd @WrayCharles @JHospMedicine The thought-processing aspect is very real. Back when I was on paper/dictation, there would be "AHA" moments as I was verbalizing parts of the history, labs, or plans. I *try* to avoid auto-populate even in the EHR to preserve some of this reflection. #JHMChat
Society of Hospital Medicine @SocietyHospMed
RT @freckledpedidoc: @ETSshow @andrewolsonmd @JHospMedicine Many of the drawbacks listed also add to the #burnout physicians experience as they deal with EMRs for billing purposes #JHMChat.
Michelle Brooks, MD @michellebr00ks
@WayneLiangMD @JHospMedicine Does this introduce bias at all? I used to teach like this until an overly persuasive student found zebras on all of their patients. #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@WayneLiangMD @JHospMedicine Another thing I teach, is if you write a symptom, or write a story, your plan should match/address it. This helps with critical thinking as well #JHMChat
Cat Doc @CatDocMD
@JHospMedicine As someone in outpatient family medicine, hospitalists discharge summaries are worth their weight in gold if someone puts effort into them. It really helps transition their inpatient care back to the outpatient world #JHMChat
Shreya P. Trivedi MD @ShreyaTrivediMD
@andrewolsonmd @MattSakumoto @medrants I like an in btw approach - i dont think every single lab value needs to be written down but the pertinent ones are helpful #JHMChat
Joseph “Dr. Joe” Thomas, MD @DocWithBowtie
@JHospMedicine #JHMCHat A1: Same as others here, billing is the most obvious, but also a story for the patient’s stay. At discharge I want to be able to look back and see what happened to put it all together. The goals of treatment and the if-then statements for getting through the night.
Andrew Olson, MD @andrewolsonmd
@freckledpedidoc @ETSshow @JHospMedicine Seems like this is a structural thing where a major activity (notes) are viewed very differently by different stakeholders --> sets up a major tension. #JHMChat
Robert Centor @medrants
Once a diagnosis is made - the assessment is much shorter - but the ongoing plan remains important #JHMChat
Society of Hospital Medicine @SocietyHospMed
Don't miss out on wisdom like this happening right now in our #JHMChat! 🔥
Gopi Astik @gopiastik
@andrewolsonmd @JHospMedicine Copying all labs and radiology results in the note is the WORST habit that even I do. I can tell on days I actually review labs/radiology and type my assessment, I comprehend it better. #JHMChat
Journal of Hospital Medicine @JHospMedicine
Wow great discussion and lots of hot takes🥞 Stay tuned. Topic 2 coming up shortly! #JHMChat
Charlie M. Wray, DO, MS @WrayCharles
@andrewolsonmd @MattSakumoto @ShreyaTrivediMD @medrants Completely agree with this technique. Instead of dumping days/weeks/months of data, I'll just write "The Cr is X, K is Y, and Na is Z." Shows my thinking, but gets rid of all the superfluous stuff #JHMChat
Daniel Wolfson @WolfsonD
I like the notion of #opennotes. What has been your experience?
Andrew Olson, MD @andrewolsonmd
@MattSakumoto @WrayCharles @JHospMedicine I find that I do my reflection about ddx when writing my notes - that is when a better ddx happens in my day, especially when admitting. #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@ShreyaTrivediMD @andrewolsonmd @MattSakumoto @medrants Definitely No one is going to use your note to figure out the labs/radiology. we should go to the *primary* source what is important, is how we interpret that data! Cr is trending up! / It peaked! / It is better! #JHMChat
Michelle Brooks, MD @michellebr00ks
@medrants @jeffreylinder This is how all consults notes were written when I did handwritten notes during medical school. Recommendations first. #JHMChat
Matt Sakumoto @MattSakumoto
@andrewolsonmd @medrants @AnnalsofIM And even as they simplified documentation for coding in 2021, the note bloat inertia is strong https://t.co/0AqN7pNJCV ht @NateApathy et al #JHMChat https://t.co/SssPlgxWHq
Anika Kumar, MD (she/her) @freckledpedidoc
@medrants @jeffreylinder Many of my sub-specialty colleagues write their consult notes in such a matter. I find that I'm usually the only person on my team who reads anything below the AP of the APSO note. #JHMChat
Robert Centor @medrants
That was exactly the original idea of the SOAP note. We included the hx (S) and physical/labs/images (O) relevant to that problem #JHMChat
Andrew Olson, MD @andrewolsonmd
@gopiastik @JHospMedicine So true!! No one likes to read a novel in place of a note! #JHMChat
Joseph “Dr. Joe” Thomas, MD @DocWithBowtie
@JHospMedicine #JHMChat A1b: I mostly try to teach students how to avoid bulk now. Copy+paste can be a tool, but it has to be thoroughly vetted and edited. No need to sound fancy when simple, goal-directed language will do. Esp now that patients can look at all notes.
Mohit Harsh, MD @MohitHarshMD
@JHospMedicine As a resident Purpose was as a thought process organizer and historical context keeper. Now on the other side it is for medical billing and *concise* thought process organizer. As I progressed my notes shortened, as did my own utilities of the written record #JHMChat
Wayne H. Liang, MD MS FAMIA FAAP @WayneLiangMD
@NdidiUnaka @JHospMedicine Agree in principle but for super complicated patients with lots of problems where should the old info go? Can’t update a separate summary every day. That’s why our notes in #bmt Tend to get longer (and longer and longer)… #JHMChat
Shreya P. Trivedi MD @ShreyaTrivediMD
@gopiastik @andrewolsonmd @JHospMedicine Agree you do internalize a bit more when you write it down but like to be selective with the ones i take the time to write down #JHMchat
Michelle Brooks, MD @michellebr00ks
@blairgolden @JHospMedicine @gopiastik 🤣🤣 #JHMChat https://t.co/WYdrggzOZs
Journal of Hospital Medicine @JHospMedicine
#JHMChat Question ✌️ : What drives “note bloat” and how do you fight it?🥊 https://t.co/IGZMqt3O04
Andrew Olson, MD @andrewolsonmd
@WrayCharles @MattSakumoto @ShreyaTrivediMD @medrants What about one step further --> "renal function improving, hyponatremia worsening, other labs stable...." etc. #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@andrewolsonmd @JHospMedicine Andrew - this is my dream I have been working on a wiki version of documentation. collaborative, dynamic, iterative. It really works..! #JHMChat
Society of Hospital Medicine @SocietyHospMed
RT @JHospMedicine: #JHMChat Question ✌️ : #JHMChat Question ✌️ : What drives “note bloat” and how do you fight it?🥊 https://t.co/IGZMqt3O04
Anika Kumar, MD (she/her) @freckledpedidoc
@michellebr00ks @andrewolsonmd @ETSshow @JHospMedicine Not to mention the carry-over functions that carry-on incorrect information/histories from note to note or even to another hospital encounter. Poor documentation... #JHMChat
Andrew Olson, MD @andrewolsonmd
@WrayCharles @MattSakumoto @ShreyaTrivediMD @medrants Also #twitter doesn't seem to recognize hyponatremia as a word which I take as a personal affront. #JHMChat
Ndidi Unaka MD, MEd @NdidiUnaka
RT @JHospMedicine: #JHMChat Question ✌️ : #JHMChat Question ✌️ : What drives “note bloat” and how do you fight it?🥊 https://t.co/IGZMqt3O04
Anika Kumar, MD (she/her) @freckledpedidoc
Great Clinical Documentation advice from Dr. @NdidiUnaka #JHMChat
Andrew Olson, MD @andrewolsonmd
@subhaairan @JHospMedicine oh oh oh tell me more and share if you can! #JHMChat
Joseph “Dr. Joe” Thomas, MD @DocWithBowtie
@JHospMedicine #JHMChat A1 pt 3: I also emphasize with H&Ps the importance of the story. Not the length, but how we arrive at our diagnosis and plan. Which is why I am a firm believer in SOAP format for progress notes, too.
Sherine Salib @DrSherineSalib
@JHospMedicine A1. As a #MedEd community, we are not intentional enough about teaching documentation skills. We assume that it’s a skill that learners can pick up.. We need a “clinical documentation curriculum”. After all, this is a huge part of what physicians do every day. #JHMChat
Matt Sakumoto @MattSakumoto
@TheRealDSrini @michellebr00ks @JHospMedicine Hi Dhruv! Great to see you here. And I tell my M3/M4s, "Cherish this time you get to write notes for pure learning and clinical benefit" (bc the regulatory, billing req all creep in later) #JHMChat
Charlie M. Wray, DO, MS @WrayCharles
@medrants @JHospMedicine Wonder if there is some ecological descriptive study to be had. VA notes (where billing is not an issue) vs. non-VA notes (where billing exists). Would imagine there are some tangible differences #JHMChat @FutureDocs @michellebr00ks
Rebecca Jaffe, MD @RJmdphilly
@andrewolsonmd @MattSakumoto @WrayCharles @JHospMedicine Wonder if that’s bc you set the time aside or the act of writing or the structured SOAP thinking you’ve been trained to do. Mix of above? #jhmchat
Bijay Acharya MD @bijayacharya
@JHospMedicine @LannaFelde Bijay, Hospitalist at @MGHMedicine Obsessed about #clinicalinformatics & #patientsafety In a love/hate relation with copy/paste #JHMChat
Robert Centor @medrants
#UncleBob opines on Q2 note bloat comes from presumed billing requirements and the ease of importing the data no one would actually type all that information #JHMChat
Society of Hospital Medicine @SocietyHospMed
RT @DrSherineSalib: @JHospMedicine A1. As a #MedEd community, we are not intentional enough about teaching documentation skills. We assume that it’s a skill that learners can pick up.. We need a “clinical documentation curriculum”. After all, this is a huge part of what physicians do every day. #JHMChat
Dhruv Srinivasachar MD (he/el/ele.) @TheRealDSrini
@JHospMedicine A2: Long stays with multiple problems being addressed and Keeping a record of things already done makes my notes bloated...this usually happens with adults or in peds Heme-onc...for general peds inpatient issues this is less of a problem #JHMChat
Mohit Harsh, MD @MohitHarshMD
@ShreyaTrivediMD @gopiastik @andrewolsonmd @JHospMedicine I had a senior resident model synopsizing results when he would work on my day off. Instead of having BMP listed in note he deleted that and wrote “BMP reviewed. Mild chronic hyponatremia, stable” I started doing this and it really helped consolidating my reasoning #JHMChat
Society of Hospital Medicine @SocietyHospMed
RT @medrants: #UncleBob opines on Q2 note bloat comes from presumed billing requirements and the ease of importing the data no one would actually type all that information #JHMChat
Wayne H. Liang, MD MS FAMIA FAAP @WayneLiangMD
@MattSakumoto @andrewolsonmd @medrants @AnnalsofIM @NateApathy Yes and providers trained in the old billing paradigm now feel this is how a note SHOULD be written (a matter of habit and professionalism)… behavior change is HARD. #JHMChat
Leonor Fernández, MD @lfernandezi
#JHMChat signing on as internist and researcher interested in notes equity and sustainable joy and meaning in our work @BIDMChealth
Matthew George, MD @MatthewGeorgeMD
I feel the cures act w/ patient access to all documentation has set up quite the conflict. We document in medical lingo to maximize illness/reimbursement and then have to walk our way back when patients question it “what do you mean I have sepsis” #JHMChat
Society of Hospital Medicine @SocietyHospMed
@bijayacharya @JHospMedicine @LannaFelde @MGHMedicine Welcome! #JHMChat
S. Trent Rosenbloom @trentrosenbloom
#JHMChat I remember building a note writing system some 25 years ago, and a great feature it had was that it could bring in other elements from the EHR all together into one place; it made it super easy to review the day's data...turns out it also made note bloat 😬 /1
Daniel Wolfson @WolfsonD
#JHMChat What has been your experience with #opennotes?
Michelle Brooks, MD @michellebr00ks
@andrewolsonmd @WrayCharles @MattSakumoto @ShreyaTrivediMD @medrants Don't tell @kidney_boy. #JHMChat https://t.co/EbSqsJmdfJ
Society of Hospital Medicine @SocietyHospMed
@lfernandezi @BIDMChealth Welcome! We're glad you're here! #JHMChat
Shreya P. Trivedi MD @ShreyaTrivediMD
@JHospMedicine Note bloat is a #systems problem. It is created by our limited #capacity to dedicate to notes bc 1. we have more interruption with pages/moving parts as things happen WAY faster for pts 2. More complex pts & care coordiantion 3. >5x Dc summaries & chart review to do #JHMchat
Mark Shapiro, MD @ETSshow
@JHospMedicine A2: cut/paste w/o proper attention to detail is by far the biggest driver of note bloat Content from antecedent days never cleaned up & properly integrated into a working document #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@WayneLiangMD @NdidiUnaka @JHospMedicine 1/2: My approach to this is a wiki. where you can archive old but important info that you dont want to lose, but dont want to see every day either. Then just pull the "active" stuff into your note. There is a huge tension btwn how we practice (iterative throug day)... #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@WayneLiangMD @NdidiUnaka @JHospMedicine and how we document (static, once a day). Also how we work (as a team!) and how we document (individually, repetitively). Documentation should be dynamic & iterative, as we practice #JHMChat
Society of Hospital Medicine @SocietyHospMed
RT @ShreyaTrivediMD: @JHospMedicine Note bloat is a #systems problem. It is created by our limited #capacity to dedicate to notes bc 1. we have more interruption with pages/moving parts as things happen WAY faster for pts 2. More complex pts & care coordiantion 3. >5x Dc summaries & chart review to do #JHMchat
Ndidi Unaka MD, MEd @NdidiUnaka
@WayneLiangMD @JHospMedicine I agree - it's a challenge! But with EMR, we can always refer to previous notes. At some point notes with medication regimens, procedures, studies etc. that happened weeks ago become less useful. #JHMChat
Rebecca Jaffe, MD @RJmdphilly
@subhaairan @ShreyaTrivediMD @andrewolsonmd @MattSakumoto @medrants Also think this is a really interesting corollary to the exam debate w @AdamRodmanMD et al. #jhmchat bottom line everything in the note should be reliable - argues hard against templated exams
Gopi Astik @gopiastik
@JHospMedicine A2: 1. Not updating the assessment and previous work up. 2. Copying and pasting all labs/radiology As said before - typing my assessment from lab and radiology review not only takes less room, it can be coded from as long as it’s not copied directly from the report. #JHMChat
Charlie M. Wray, DO, MS @WrayCharles
I love and appreciate how @ShreyaTrivediMD always is able to bring the systems-issues that impact our world. #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@MatthewGeorgeMD there is a big difference between a BILLING problem list and a CLINICAL problem list. This tension causes so much frustrating when documenting in current state of EHRs #JHMChat
Michelle Brooks, MD @michellebr00ks
A2: I still need to orient to CPRS this week, but in Cerner and Epic, I feel like the problem list was not as useful as it could be and contributed to "note bloat." #JHMChat
S. Trent Rosenbloom @trentrosenbloom
#JHMChat When I think of note bloat, I think of notes that are trying to do many things - recall prior work on the patient, facilitate daily clinical data review, snapshot the patient condition in that moment, reduce typing burden. All that encourages me to pull EVERYTHING in. /2
Yichi Zhang (张一弛) @YichiZzzzz
@JHospMedicine A2: Honestly, EHR templates have a lot to do with this... They are so convenient, but also make it easy for us to include a bunch of extraneous things we do not need. And as students we're often just told to copy-paste the template that the attending uses for simplicity #JHMChat
Journal of Hospital Medicine @JHospMedicine
Great point! #JHMChat
Blair Golden @blairgolden
@JHospMedicine A2. I think there's a belief that it takes less time to add on to a note rather than do daily updates. Hand-offs can also contribute because there’s a fear that info will be "lost"- but info is still in the chart & an excessively long, outdated note doesn’t help anyone! #JHMChat
Vinny Arora MD MAPP @FutureDocs
@JHospMedicine A2 the infamous CoPaGA syndrome - copy and past gone amok. information anxiety works both ways - ok to let go of old info and synthesize to avoid the “wiki” type narratives we have now #jhmchat
Subha Airan-Javia (she/her) @subhaairan
@MattSakumoto @andrewolsonmd @WrayCharles @JHospMedicine This is why when the attg writes their notes in the afternoon, they have so many more recs! Bc we have thought through things in more detail as we write! #JHMChat
Mohit Harsh, MD @MohitHarshMD
@JHospMedicine A2: institutional requirements of note context, lack of learning how to personalize dot phrases (lots of cognitive load to get fancy with epic with no guidance), feeling like all compounded info historically must be included in each progress note, copy pasted data #JHMChat
Joseph “Dr. Joe” Thomas, MD @DocWithBowtie
@JHospMedicine #JHMChat A2: As much as Copy+Paste can be utilized when you have so many notes to write, it MUST be heavily edited. I don’t need the daily play-by-play “to make the DC summary is easier to write (that said, I like that Epic gives a space for that because it’s a challenge).”
Andrew Olson, MD @andrewolsonmd
@NdidiUnaka @JHospMedicine Love this - and ok to have a discharge summary in progress to not lose this data! #JHMChat
Wayne H. Liang, MD MS FAMIA FAAP @WayneLiangMD
@michellebr00ks @JHospMedicine Interesting question. Maybe there is a balance. My experience is most students/trainees start with incoherent info dump and leave out the “so what”, rather than other way around. #JHMChat
Journal of Hospital Medicine @JHospMedicine
@bijayacharya @LannaFelde @MGHMedicine Welcome Bijay! Thanks for joining #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@michellebr00ks @WayneLiangMD @JHospMedicine this is an interesting question... I need to ponder on it! I guess it needs to be coupled with "think critically and avoid anchoring bias" #JHMChat
Anika Kumar, MD (she/her) @freckledpedidoc
@JHospMedicine T2. 1️⃣ Carry over function. 2️⃣a. The tension @andrewolsonmd discussed between clinical communication & billing. 2️⃣b. Lack of understanding on the purpose of the note. 3️⃣. Worry that something important will be "missed." #JHMChat
Blair Golden @blairgolden
@JHospMedicine A2b. I invest a few minutes each day to summarize issues and update my to-do list. As others have suggested, I also cut out info that people will find elsewhere in the chart, like imaging reports. #JHMChat
Ndidi Unaka MD, MEd @NdidiUnaka
Yes, to this. I love the cut and paste function - it is critical for efficiency. But it does not replace the need for careful review! #JHMChat
Shreya P. Trivedi MD @ShreyaTrivediMD
RT @subhaairan: @MatthewGeorgeMD there is a big difference between a BILLING problem list and a CLINICAL problem list. This tension causes so much frustrating when documenting in current state of EHRs #JHMChat
S. Trent Rosenbloom @trentrosenbloom
#JHMChat Fundamentally, we need to change how we document, what we document, and why we document. We need to decouple billing from note writing, make it easier to review things in the EHR, and revisit documentation guidelines. More at #25x5 https://t.co/Z9Y5MEXSMG /fin
Andrew Olson, MD @andrewolsonmd
@WayneLiangMD @michellebr00ks @JHospMedicine I think that reasoning is different than persuasion - also MUST include uncertainty which we are often loath to do. #JHMChat
Journal of Hospital Medicine @JHospMedicine
@lfernandezi @BIDMChealth Welcome Leonor! #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@CatDocMD @JHospMedicine "What is in a good discharge summary:" could be a whole nother chat topic! #JHMChat
Shreya P. Trivedi MD @ShreyaTrivediMD
RT @WrayCharles: I love and appreciate how @ShreyaTrivediMD always is able to bring the systems-issues that impact our world. #JHMChat
Matt Sakumoto @MattSakumoto
@ETSshow @JHospMedicine I always reference the "Sloppy and Paste" article by Hirshtick on the pitfalls of copy-forward. #JHMChat https://t.co/OtknOnz7gh
Charlie M. Wray, DO, MS @WrayCharles
@JHospMedicine The saying "I would have written a shorter note, but I didn't have time" comes to mind. #JHMChat
Journal of Hospital Medicine @JHospMedicine
Great point Matthew #JHMChat
Joseph “Dr. Joe” Thomas, MD @DocWithBowtie
@JHospMedicine #JHMChat A2b: Need to eliminate bulk phrases like “continue to monitor” and replace with goal-directed bullet points. I also find that folks are eliminating the assessment statement. To me a good, current assessment 1-to-2-liner is SO useful! Part of the art of writing.
Michelle Brooks, MD @michellebr00ks
RT @MattSakumoto: @ETSshow @JHospMedicine I always reference the "Sloppy and Paste" article by Hirshtick on the pitfalls of copy-forward. #JHMChat https://t.co/OtknOnz7gh
Jess Dreicer, MD @jessdreicer
@JHospMedicine A2. This happens when daily progress notes are used as surrogates for discharge summaries. When I see that I tell my learners to focus on changes in the last 24 hours and move the background info into the actual DC summary. Only new problems should have a lot of text. #JHMChat
Mohit Harsh, MD @MohitHarshMD
@JHospMedicine A2: I think also repetitive info in multiple locations. “S: feeling well cr elevated to 2.0 today (bl 1.5). UOP good, sending urine lytes” Also then gets pasted in objective data Also gets included in A/P. Compartmentalize! #JHMChat
Shreya P. Trivedi MD @ShreyaTrivediMD
@DrSherineSalib @JHospMedicine Agree! Who are the best teachers (enough bandwidth & expertise) to teach a clinical documentation #curriculum?! #JHMchat
Anika Kumar, MD (she/her) @freckledpedidoc
@andrewolsonmd @WrayCharles @MattSakumoto @ShreyaTrivediMD @medrants Exactly!! I tell my trainees their assessments must include if things are better, worse or the same in comparison to the prior day's documentation. #jhmchat
Subha Airan-Javia (she/her) @subhaairan
@WrayCharles @andrewolsonmd @MattSakumoto @ShreyaTrivediMD @medrants I actually FORCE myself to write out key labs and my own trends. similar to writing on paper, the act of doing it helps me remember it & forces me to think about it more critically. Takes time, but worth it! WBC 6 <-- 10 Hg 8.2 <-- 9.7 etc #JHMChat
Andrew Olson, MD @andrewolsonmd
@JHospMedicine A2) We conflate inclusion of data with inclusion of information.... our job is synthesis not just including data but I think our push for billing has confused this! #JHMChat
Anika Kumar, MD (she/her) @freckledpedidoc
RT @andrewolsonmd: @JHospMedicine Seeing all these great responses makes me wonder - what if we were to "invent" the note in the EHR era? We we wouldn't document much "data" at all since it is elsewhere. We used to do that because it was hard to find, but now it is our thinking/rationale that matters. #JHMChat
Wayne H. Liang, MD MS FAMIA FAAP @WayneLiangMD
@andrewolsonmd @michellebr00ks @JHospMedicine Agree that reasoning is a better word than persuasion, since wouldn’t want to deemphasize data that goes against the the recommendation. #JHMChat
Mark Shapiro, MD @ETSshow
@NdidiUnaka The Highly Sought-After @NdidiUnaka QT! Achievement Unlocked! Appreciate you. Go Bruins #JHMChat
Society of Hospital Medicine @SocietyHospMed
RT @jessdreicer: @JHospMedicine A2. This happens when daily progress notes are used as surrogates for discharge summaries. When I see that I tell my learners to focus on changes in the last 24 hours and move the background info into the actual DC summary. Only new problems should have a lot of text. #JHMChat
Bijay Acharya MD @bijayacharya
@andrewolsonmd @subhaairan @YichiZTulane @JHospMedicine Still need to delete ddx as new info comes in. Copy/Paste and Copy/Forward leads to note bloat. #jhmchat
Mark Shapiro, MD @ETSshow
RT @NdidiUnaka: Yes, to this. I love the cut and paste function - it is critical for efficiency. But it does not replace the need for careful review! #JHMChat
S. Trent Rosenbloom @trentrosenbloom
@MatthewGeorgeMD A great point, but important to remember that under HIPAA patients have always had the right to access their entire medical record. The 21st Century Cures Act exists in part because too many health systems and vendors nonetheless blocked access. #JHMChat
Journal of Hospital Medicine @JHospMedicine
@NdidiUnaka @WayneLiangMD Great point Ndidi. Some EMRs also have a search function. #JHMChat
Michelle Brooks, MD @michellebr00ks
@MohitHarshMD @JHospMedicine I often give this feedback. You'll get to it if you follow a structure!! Eliminate the redundancy. #JHMChat
Charlie M. Wray, DO, MS @WrayCharles
Honest question, has being on Twitter helped you write more concise clinical notes? #JHMChat For me, the answer is absolutely.
Subha Airan-Javia (she/her) @subhaairan
@freckledpedidoc @medrants @jeffreylinder I agree. Though I do want to plug for making sure that the clinical reasoning is there. With consultants esp, i want to know WHY you are making the recommendations you are. :) #JHMChat
Society of Hospital Medicine @SocietyHospMed
⏲️ This #JHMChat is 🔥! Hop in and share your insight on clinical documentation. 🤔 ✅ Connect with your hospitalist community ✅ Share advice ✅ Learn tips Use #JHMChat on all replies to be part of the conversation!
S. Trent Rosenbloom @trentrosenbloom
RT @MattSakumoto: @ETSshow @JHospMedicine I always reference the "Sloppy and Paste" article by Hirshtick on the pitfalls of copy-forward. #JHMChat https://t.co/OtknOnz7gh
Andrew Olson, MD @andrewolsonmd
@ShreyaTrivediMD @DrSherineSalib @JHospMedicine Maybe a controversial take here but why not just have this be a national curriculum? Develop it and use everywhere? Maybe this is something (for hospital IM/Peds at least that we all could own... #JHMChat
Bijay Acharya MD @bijayacharya
@MohitHarshMD @ShreyaTrivediMD @gopiastik @andrewolsonmd @JHospMedicine relevant labs help others and patients understand what their doctors are thinking. #jhmchat
Charlie M. Wray, DO, MS @WrayCharles
@DocWithBowtie @JHospMedicine I take immense pleasure deleting "continue to monitor" or "appreciate subspecialist", etc. #JHMChat
Mark Shapiro, MD @ETSshow
@DrSherineSalib @JHospMedicine #JHMChat https://t.co/7StfffRJuv
Subha Airan-Javia (she/her) @subhaairan
@DocWithBowtie @JHospMedicine Agree, it has utility when used thoughtfully Some places have blocked it completely and force people to write/dictate from scratch every day. I do NOT think that is the right answer and leads to information scatter & things getting lost #JHMChat
Anika Kumar, MD (she/her) @freckledpedidoc
@DrSherineSalib @JHospMedicine Couldn't agree with you more. It's something we teach our PHM Fellows but what we teach in medical school isn't what is practiced. We must revamp the curriculum. #JHMChat
Charlie M. Wray, DO, MS @WrayCharles
@subhaairan @CatDocMD @JHospMedicine Duly noted, Subha #JHMChat
Matt Sakumoto @MattSakumoto
@subhaairan @CatDocMD @JHospMedicine As a PCP on the receiving end of these "Transitions of Care" I have many thoughts on a good discharge summary :) #JHMChat
Andrew Olson, MD @andrewolsonmd
@subhaairan @freckledpedidoc @medrants @jeffreylinder I used to despise the APSO approach until our template (grumble grumble) went to it, now I love it. I include my reasoning in the AP which I hope people read. #JHMChat
Mohit Harsh, MD @MohitHarshMD
@WrayCharles @JHospMedicine Takes a lot of effort to be succinct. In the times that I have intentionally shortened the note, my reasoning on the patient had significantly improved! #JHMChat
S. Trent Rosenbloom @trentrosenbloom
RT @WrayCharles: Honest question, has being on Twitter helped you write more concise clinical notes? #JHMChat For me, the answer is absolutely.
Sherine Salib @DrSherineSalib
@JHospMedicine A2. In addition to the template-based notes & systems issues, “note bloat” arises because we keep asking learners to add more to their notes to satisfy coding & billing requirements. We need to get to the root of the problem. Our learners are getting mixed messages… #JHMChat
Journal of Hospital Medicine @JHospMedicine
Excellent points! We know you're hungry for more. #JHMChat question 3️⃣ is coming right up! 🍳
Andrew Olson, MD @andrewolsonmd
@WrayCharles @subhaairan @CatDocMD @JHospMedicine During my days @UCSFIMChiefs I learned that every discharge summary can fit on two pages or less. No matter what. #challengeaccepted. #JHMChat
Eric Schultz @ericschul
Definitely
Shreya P. Trivedi MD @ShreyaTrivediMD
@WrayCharles Yes twitter has made me an amazing word-smither and almost have an allergy to large blocks of texts of word vomit #JHMchat
Blair Golden @blairgolden
@WrayCharles @JHospMedicine So true! I view my notes as a form of writing and brevity is always TOUGH. #JHMChat
Temple Ratcliffe, MD, MS-HPEd @templeratcliffe
RT @andrewolsonmd: @JHospMedicine A2) We conflate inclusion of data with inclusion of information.... our job is synthesis not just including data but I think our push for billing has confused this! #JHMChat
Mohit Harsh, MD @MohitHarshMD
@YichiZTulane @JHospMedicine It is a massive undertaking to teach proper note writing on top of core medical knowledge. Self perpetuating cycle #JHMChat
Charlie M. Wray, DO, MS @WrayCharles
@subhaairan @andrewolsonmd @MattSakumoto @ShreyaTrivediMD @medrants Me too! But arrows to the left! I'm and arrows to the right (for me I think/read temporally) #JHMChat
Vinny Arora MD MAPP @FutureDocs
@JHospMedicine We created a shared discharge summary note that can be drafted during the hospital stay and shared among multiple people so daily notes aren’t seen in this “must contain everything” lens #jhmchat
Subha Airan-Javia (she/her) @subhaairan
@FutureDocs @JHospMedicine Wait, please dont bash the wiki! Wiki's can be good...what we don't want is a long running collective narrative. I think the biggest contributors to note bloat are: 1) poorly designed systems/EHRs 2) regulatory/billing requirements 3) volume #JHMChat
Matt Sakumoto @MattSakumoto
@WrayCharles Yes! Twitter has trained my more concise notes...Even down to the hashtags #JHMChat https://t.co/wHGxpCStK5
Society of Hospital Medicine @SocietyHospMed
RT @FutureDocs: @JHospMedicine We created a shared discharge summary note that can be drafted during the hospital stay and shared among multiple people so daily notes aren’t seen in this “must contain everything” lens #jhmchat
Journal of Hospital Medicine @JHospMedicine
@subhaairan @CatDocMD Great idea!!! @WrayCharles, @michellebr00ks, @NdidiUnaka and I will get right on that 😄 #JHMChat
Andrew Olson, MD @andrewolsonmd
@blairgolden @WrayCharles @JHospMedicine yes totally - as my notes have gotten more brief (but not worse) I have had to get over some guilt! #JHMChat
Rebecca Jaffe, MD @RJmdphilly
Note bloat is almost 100% due to the inefficiency of all other work, compelling the creation of bad work arounds to try to increase the efficiency of note writing as compensation, leading note reading to be a waste of time. (Only minor hyperbole?) #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@WrayCharles @DocWithBowtie @JHospMedicine but i REALLY APPRECIATE YOU! #JHMChat
Anika Kumar, MD (she/her) @freckledpedidoc
@WrayCharles Yes!! Absolutely!! It's also made me use more robust vocabulary! #JHMChat
Mohit Harsh, MD @MohitHarshMD
RT @DrSherineSalib: @JHospMedicine A1. As a #MedEd community, we are not intentional enough about teaching documentation skills. We assume that it’s a skill that learners can pick up.. We need a “clinical documentation curriculum”. After all, this is a huge part of what physicians do every day. #JHMChat
Vinny Arora MD MAPP @FutureDocs
@subhaairan @JHospMedicine I must not have seen a good wiki ! #jhmchat https://t.co/n7h2VL01wh
Bijay Acharya MD @bijayacharya
@ShreyaTrivediMD @JHospMedicine Note bloat also has downstream effect. Long notes lead to long discharge summaries that is hard to understand by PCP and by admitting team in the future. #jhmchat
Ndidi Unaka MD, MEd @NdidiUnaka
@ETSshow LOL! Go Ducks! #JHMChat
Andrew Olson, MD @andrewolsonmd
@FutureDocs @JHospMedicine LOVE THIS! (someone should make you a dean or something) How is uptake/adoption? #JHMChat
Mark Shapiro, MD @ETSshow
@andrewolsonmd @WrayCharles @subhaairan @CatDocMD @JHospMedicine @UCSFIMChiefs I always pretend I’m the person reading a discharge summary I’m writing What do I want/need to see? What is not relevant/distracting? What would make me feel frustrated to not have included? #JHMChat
Anika Kumar, MD (she/her) @freckledpedidoc
@andrewolsonmd @subhaairan @medrants @jeffreylinder If the clinical reasoning isn't documented, why are we documenting? #JHMChat
Society of Hospital Medicine @SocietyHospMed
RT @ETSshow: @andrewolsonmd @WrayCharles @subhaairan @CatDocMD @JHospMedicine @UCSFIMChiefs I always pretend I’m the person reading a discharge summary I’m writing What do I want/need to see? What is not relevant/distracting? What would make me feel frustrated to not have included? #JHMChat
Andrew Olson, MD @andrewolsonmd
@subhaairan @WrayCharles @DocWithBowtie @JHospMedicine #thankyouforthisinterestingconsult #not #JHMChat
Journal of Hospital Medicine @JHospMedicine
#JHMChat Question 3️⃣: The 21st Century Cures Act 📜 has made clinical notes more accessible to patients. How has this changed your practice?🤔 https://t.co/N4EUPB4wso
Journal of Hospital Medicine @JHospMedicine
@jessdreicer Great thoughts Jess. I find that Epic doesn't have a good way to have an ongoing DC summary that you work on throughout the admission. Is this different from your experience? #JHMChat
vumcDBMI @vumcdbmi
RT @trentrosenbloom: #JHMChat I remember building a note writing system some 25 years ago, and a great feature it had was that it could bring in other elements from the EHR all together into one place; it made it super easy to review the day's data...turns out it also made note bloat 😬 /1
Society of Hospital Medicine @SocietyHospMed
RT @JHospMedicine: #JHMChat Question 3️⃣: #JHMChat Question 3️⃣: The 21st Century Cures Act 📜 has made clinical notes more accessible to patients. How has this changed your practice?🤔 https://t.co/N4EUPB4wso
vumcDBMI @vumcdbmi
RT @trentrosenbloom: #JHMChat When I think of note bloat, I think of notes that are trying to do many things - recall prior work on the patient, facilitate daily clinical data review, snapshot the patient condition in that moment, reduce typing burden. All that encourages me to pull EVERYTHING in. /2
vumcDBMI @vumcdbmi
RT @trentrosenbloom: #JHMChat Fundamentally, we need to change how we document, what we document, and why we document. We need to decouple billing from note writing, make it easier to review things in the EHR, and revisit documentation guidelines. More at #25x5 https://t.co/Z9Y5MEXSMG /fin
Wayne H. Liang, MD MS FAMIA FAAP @WayneLiangMD
@JHospMedicine #JHMChat Q2 what drives #notebloat: - billing - lack of time/interest in writing concisely - copy/paste - frequent provider handovers — feeling the need to keep a running acct of patient story - #EHR not supporting data review elsewhere as “documentation” - auto generated text
Andrew Olson, MD @andrewolsonmd
WE HAVE REACHED THE SHOUTY CAPS AMPLIFICATION PORTION OF THE EVENING. SEE THIS TWEET AND REMEMBER IT!!! #JHMChat
Matthew George, MD @MatthewGeorgeMD
RT @MatthewGeorgeMD: I feel the cures act w/ patient access to all documentation has set up quite the conflict. We document in medical lingo to maximize illness/reimbursement and then have to walk our way back when patients question it “what do you mean I have sepsis” #JHMChat
vumcDBMI @vumcdbmi
RT @trentrosenbloom: #JHMChat Documentation serves many - too many - purposes. We'd like to think it should be for communication, recording observations and considerations, and education, there are many more stakeholders that value the work we do when writing notes. This now includes engaged patients
vumcDBMI @vumcdbmi
RT @trentrosenbloom: #JHMChat The multiple uses for the note are fine so long as they contribute to healthcare delivery broadly defined. They are problematic when they lead to burden. #25x5
Shreya P. Trivedi MD @ShreyaTrivediMD
@JHospMedicine Burnout answer: "There is no time to change practice in a surge" #JHMchat
Wayne H. Liang, MD MS FAMIA FAAP @WayneLiangMD
RT @trentrosenbloom: #JHMChat I remember building a note writing system some 25 years ago, and a great feature it had was that it could bring in other elements from the EHR all together into one place; it made it super easy to review the day's data...turns out it also made note bloat 😬 /1
Vinny Arora MD MAPP @FutureDocs
@andrewolsonmd @JHospMedicine It was an idea from several residents submitted to our “what to fix” program since patients have lots of handoffs and the discharge planning can literally start on admission. crafting a discharge summary can be incredibly challenging if you didn’t know the patient. #jhmchat
vumcDBMI @vumcdbmi
RT @WrayCharles: Honest question, has being on Twitter helped you write more concise clinical notes? #JHMChat For me, the answer is absolutely.
Anika Kumar, MD (she/her) @freckledpedidoc
@andrewolsonmd @ShreyaTrivediMD @DrSherineSalib @JHospMedicine Agree. I think Inpatient providers are also where more note bloat happens (at least in my Peds practice). #JHMChat
Mark Shapiro, MD @ETSshow
RT @NdidiUnaka: @ETSshow LOL! Go Ducks! #JHMChat
Joseph “Dr. Joe” Thomas, MD @DocWithBowtie
@WrayCharles @subhaairan @andrewolsonmd @MattSakumoto @ShreyaTrivediMD @medrants I am also arrows to the right, but I very much appreciate that when actively monitoring lab trends, the ones that are keeping them there. #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@blairgolden @JHospMedicine The interplay btwn handoffs & notes is a THING. they are a ven diagram & traditional EHRs/tools force duplicative work. we should have ONE, iterative plan that we work on throughout the day, that then produces a day/night handoff view AND daily note write it ONCE #JHMChat
Mohit Harsh, MD @MohitHarshMD
@JHospMedicine A3: it hasn’t #JHMChat
Michelle Brooks, MD @michellebr00ks
RT @andrewolsonmd: WE HAVE REACHED THE SHOUTY CAPS AMPLIFICATION PORTION OF THE EVENING. SEE THIS TWEET AND REMEMBER IT!!! #JHMChat
Andrew Olson, MD @andrewolsonmd
@JHospMedicine After some initial trepidation, I think this has with very few exceptions made me and my notes better. I have conversations that need to be had and also find I am (hopefully) less biased in my notes. #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@freckledpedidoc @michellebr00ks @andrewolsonmd @ETSshow @JHospMedicine i'm researching this right now! How much do things get replicated ....! #JHMChat
Society of Hospital Medicine @SocietyHospMed
RT @andrewolsonmd: WE HAVE REACHED THE SHOUTY CAPS AMPLIFICATION PORTION OF THE EVENING. SEE THIS TWEET AND REMEMBER IT!!! #JHMChat
Robert Centor @medrants
#UncleBob - since I work at the VA, I have never considered this issue. I do try to be thoughtful in the way I refer to patients and differential diagnoses. #JHMChat
Vinny Arora MD MAPP @FutureDocs
@andrewolsonmd @JHospMedicine Adoption is good! Plus we do have lots of interventions targeted at note bloat (better templates) by our IT team with our Hospitalists #jhmchat
Subha Airan-Javia (she/her) @subhaairan
@WrayCharles @medrants @JHospMedicine @FutureDocs @michellebr00ks This is interesting. A huge factor in quality of notes though, is how the system is designed. Much of our note practices are a factor of the systems we use People. Process. Technology. All three affect the outcome #JHMChat
Journal of Hospital Medicine @JHospMedicine
Deleting text from my notes like: #JHMChat https://t.co/ESAOuIFuHy
Charlie M. Wray, DO, MS @WrayCharles
@ETSshow @andrewolsonmd @subhaairan @CatDocMD @JHospMedicine @UCSFIMChiefs Totally agree, Mark. I urge all trainees to use the following format -right at the top of the DC summary (so it's not missed): [ ] First, do this... [ ] Also, the patient needs this.. [ ] And watch out for... Basically, structure can be used to your audiences advantage #JHMChat
Andrew Olson, MD @andrewolsonmd
@DocWithBowtie @WrayCharles @subhaairan @MattSakumoto @ShreyaTrivediMD @medrants I love that us hospitalists are legitimately having an arrows to the right or left convo. These are my people. #JHMChat
Wayne H. Liang, MD MS FAMIA FAAP @WayneLiangMD
RT @WrayCharles: @JHospMedicine The saying "I would have written a shorter note, but I didn't have time" comes to mind. #JHMChat
Wayne H. Liang, MD MS FAMIA FAAP @WayneLiangMD
RT @MattSakumoto: @ETSshow @JHospMedicine I always reference the "Sloppy and Paste" article by Hirshtick on the pitfalls of copy-forward. #JHMChat https://t.co/OtknOnz7gh
Mohit Harsh, MD @MohitHarshMD
@JHospMedicine A3: I had beforehand changed my language to more patient centered documentation but I imagine for those that continue to use alcoholic, opioid addict, including race in HPI etc it may change their habits. I hope at least. #JHMChat
Blair Golden @blairgolden
@FutureDocs @andrewolsonmd @JHospMedicine I love this approach! I also like that it allows for ongoing, direct coaching and collaboration on discharge summaries #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@bijayacharya @JHospMedicine @LannaFelde @MGHMedicine me toooooooooo! #JHMChat
Michelle Brooks, MD @michellebr00ks
@JHospMedicine A3: it hasn’t, but it might. One patient’s spouse told me my notes were horrible. And Epic put the problem list in alphabetical order, so “alcohol use disorder” seemed like the primary diagnosis, which was a valid criticism. #JHMChat
Bijay Acharya MD @bijayacharya
@JHospMedicine When you have a poor #system, difficult #userinterface of #EHRs, billing pressures and interruptions, we default to the path of least resistance - Copy/Forward. I mostly devoted my day 1 of service to delete redundant problems and statements. #jhmchat
Andrew Olson, MD @andrewolsonmd
That's it. That's the tweet! #JHMChat
Dhruv Srinivasachar MD (he/el/ele.) @TheRealDSrini
@JHospMedicine A3: Has made it very clear that documentation needs to be clear to multiple different parties, from other doctors to patients. Also note to particularly old white cis men doctors...do not use notes to disparage patients...I still see some of that...#JHMChat
Wayne H. Liang, MD MS FAMIA FAAP @WayneLiangMD
RT @andrewolsonmd: @JHospMedicine A2) We conflate inclusion of data with inclusion of information.... our job is synthesis not just including data but I think our push for billing has confused this! #JHMChat
S. Trent Rosenbloom @trentrosenbloom
#JHMChat it has not. I have provided my notes for patients for years, and occasionally co-document (meaning share my monitor with the patient when writing the note).
Eric Schultz @ericschul
@JHospMedicine Always writing as if the patient or their family might be reading. Further reminder to avoid judgmental or stigmatizing language like “poor historian” or “non-compliant.” Important to reinforce with trainees. #JHMChat
Sherine Salib @DrSherineSalib
@andrewolsonmd @ShreyaTrivediMD @JHospMedicine Absolutely! Let’s reclaim clinical documentation! It’s an important part of patient care that’s gotten a bad rap over the years… #JHMChat
Yichi Zhang (张一弛) @YichiZzzzz
@JHospMedicine A2: Definitely had been taught to be more aware of the tone of the language by my team. Recently when seeing adolescent patients in #peds clinic, it has been more challenging to document (ie. Sexual history, HEADSSS assessment etc). #JHMChat.
Rebecca Jaffe, MD @RJmdphilly
@freckledpedidoc @andrewolsonmd @ShreyaTrivediMD @DrSherineSalib @JHospMedicine Yes but also reading most outpatient notes I’m left with NO clinical reasoning. More like a list of problems and associated orders. I get my most insight from the rare copy forwarded 5 year rheum Hx with a one sentence update at every 3 month visit. #jhmchat
Andrew Olson, MD @andrewolsonmd
@WrayCharles @ETSshow @subhaairan @CatDocMD @JHospMedicine @UCSFIMChiefs we have a section in our discharge summary template at the top that says PCP TO DO and it is the most important section of our summary. #JHMChat
Dhruv Srinivasachar MD (he/el/ele.) @TheRealDSrini
@MohitHarshMD @JHospMedicine Yep, and make sure the next generation doesn't develop what we euphemistically call "bad habits" in documentation #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@trentrosenbloom back when it wasn't easy to find all that data, this was a GREAT tool now that our tech has changed, the way we generate and record notes needs to change too #JHMChat
Shreya P. Trivedi MD @ShreyaTrivediMD
@WrayCharles @ETSshow @andrewolsonmd @subhaairan @CatDocMD @JHospMedicine @UCSFIMChiefs Yes all the @BIDMC_IM residents have a clear actionable transitional issue up at the very top and have changed my practice to do the same #Alwayslearning #JHMchat
Wayne H. Liang, MD MS FAMIA FAAP @WayneLiangMD
Love this
Ndidi Unaka MD, MEd @NdidiUnaka
@DrSherineSalib @JHospMedicine Agree! At times we can reinforce note-writing behaviors in trainees that are neither necessary or sustainable. A long, overly detailed note is nice but at what cost? I want trainee notes to be accurate and thoughtful. I also want them to spend more time at the bedside #JHMChat
Matt Sakumoto @MattSakumoto
@WrayCharles @ETSshow @andrewolsonmd @subhaairan @CatDocMD @JHospMedicine @UCSFIMChiefs We are hardwired to respond to checklists (s/o Checklist Manifesto) and this PCP on the receiving end thanks you for the clear, concise post-dc guidance *at the top* #JHMChat https://t.co/Ts6BXHPHy3
Rebecca Jaffe, MD @RJmdphilly
@subhaairan @blairgolden @JHospMedicine #writeitonce should be a movement #jhmchat
Gopi Astik @gopiastik
@JHospMedicine A3: it hasn’t changed my practice much except I try to make sure the discharge summary is readable because it’s the note more people access. #JHMChat
Bijay Acharya MD @bijayacharya
@FutureDocs @andrewolsonmd @JHospMedicine @FutureDocs - is this a template based document? How do you keep track of what in d/c summary is "important"? Do you have any shareable best practices? #jhmchat
Mark Shapiro, MD @ETSshow
@JHospMedicine A3: I am quite sure anytime I get feedback from a patient about something I could have documented differently will be challenging. Will also be an amazing learning opportunity Step into the tension indeed! #JHMChat
Anika Kumar, MD (she/her) @freckledpedidoc
@WrayCharles @ETSshow @andrewolsonmd @subhaairan @CatDocMD @JHospMedicine @UCSFIMChiefs To your point early @WrayCharles, my DC summaries have become much more succinct after Twitter. Also, most PHM patients have 1-3 problems so they don't need a novel of a DC summary. PCPs (general pediatricians in my case) have less than 1 minute to read the FV summary. #jhmchat
Joseph “Dr. Joe” Thomas, MD @DocWithBowtie
@JHospMedicine #JHMChat A3: I DO try to keep my patients in mind, as if they’re looking at the notes, more so now than I used to. It makes me remember person-first language vs. biased language. How do I convey the challenges of this hospitalization as part of a partnership with my patient?
Andrew Olson, MD @andrewolsonmd
@blairgolden @FutureDocs @JHospMedicine It seems that there are pretty different purposes between DC summaries and daily notes - yet we rely on the latter to make the former - thus @FutureDocs your innovation is brilliant. #JHMChat
Mark Shapiro, MD @ETSshow
@WrayCharles @andrewolsonmd @subhaairan @CatDocMD @JHospMedicine @UCSFIMChiefs Fist-bump emoji to you my friend #JHMChat
Mark Shapiro, MD @ETSshow
RT @WrayCharles: @ETSshow @andrewolsonmd @subhaairan @CatDocMD @JHospMedicine @UCSFIMChiefs Totally agree, Mark. I urge all trainees to use the following format -right at the top of the DC summary (so it's not missed): [ ] First, do this... [ ] Also, the patient needs this.. [ ] And watch out for... Basically, structure can be used to your audiences advantage #JHMChat
Leonor Fernández, MD @lfernandezi
@JHospMedicine #JHMChat Have you @MatthewGeorgeMD or others found that patients reading inpatient notes has been negative? Does it improve communication with family?
Subha Airan-Javia (she/her) @subhaairan
@RJmdphilly @ShreyaTrivediMD @andrewolsonmd @MattSakumoto @medrants @AdamRodmanMD it is so true. tbh i do have shortcuts for my exam, but I do them for each system individually. that way i think through each system and edit as i go. and it is STILL too easy to forget to update something. #JHMChat
Andrew Olson, MD @andrewolsonmd
@NdidiUnaka @DrSherineSalib @JHospMedicine I worry that we celebrate thoroughness early on without talking about synthesis and brevity - we get what we reinforce. #JHMChat
S. Trent Rosenbloom @trentrosenbloom
RT @subhaairan: @trentrosenbloom back when it wasn't easy to find all that data, this was a GREAT tool now that our tech has changed, the way we generate and record notes needs to change too #JHMChat
Dhruv Srinivasachar MD (he/el/ele.) @TheRealDSrini
@DocWithBowtie @JHospMedicine And even with this some groups want Identity-first language (particularly autistic patients) #JHMChat
Matt Sakumoto @MattSakumoto
@andrewolsonmd @ShreyaTrivediMD @DrSherineSalib @JHospMedicine National Note-writing curriculum sounds like something the @HOMERuN_Network #MedEd WG can take a look at. We should chat more @andrewolsonmd ! tag @Pahwa #JHMChat #WorldsCollide
Blair Golden @blairgolden
@medrants A3. I was initially anxious, but this has just made me more deliberate about trying to do what I always should: communicate effectively, be transparent w/ patients re: the care plan & test results, and never engage in chart war (which no one wins!) #JHMChat
Society of Hospital Medicine @SocietyHospMed
RT @blairgolden: @medrants A3. I was initially anxious, but this has just made me more deliberate about trying to do what I always should: communicate effectively, be transparent w/ patients re: the care plan & test results, and never engage in chart war (which no one wins!) #JHMChat
Ndidi Unaka MD, MEd @NdidiUnaka
@andrewolsonmd @DrSherineSalib @JHospMedicine Yes we do!!! #JHMChat
Frank Cacace MD FACP @GIMaPreceptor
@templeratcliffe Right here! Right here is mostly why my HPI &a/p can go a bit long on my clinic notes - I know this is #jhmchat , &I’m in office, but @templeratcliffe ‘s chat comment hit me in the workflows Writing IS thinking, and differentiating for new concerns, planning/framing next visit
Andrew Olson, MD @andrewolsonmd
@RJmdphilly @subhaairan @ShreyaTrivediMD @MattSakumoto @medrants @AdamRodmanMD This is the SO part of the note I never use autotext etc for - I take real joy in documenting my physical exam. #JHMChat
Ndidi Unaka MD, MEd @NdidiUnaka
RT @andrewolsonmd: @NdidiUnaka @DrSherineSalib @JHospMedicine I worry that we celebrate thoroughness early on without talking about synthesis and brevity - we get what we reinforce. #JHMChat
Matthew George, MD @MatthewGeorgeMD
#JHMChat with cures act, when I say patients question me, has nothing to do with me saying anything offensive or factually wrong. Has all to do with lingo. “Acute failure “, “metabolic encephalopathy”, “severe sepsis with organ dysfunction” they get very concerned with severity
Vinny Arora MD MAPP @FutureDocs
@bijayacharya @andrewolsonmd @JHospMedicine Not a template just a function of the note type. There’s definitely work @JenCMyers has done in this area! #jhmchat
Rebecca Jaffe, MD @RJmdphilly
@bijayacharya @JHospMedicine As do I. As, seemingly, does everyone else. Which makes me wonder how our standards slip from day 1 to day 7. Or if we all just need to create from scratch in order to “get it.” #jhmchat
Gopi Astik @gopiastik
@MattSakumoto @andrewolsonmd @ShreyaTrivediMD @DrSherineSalib @JHospMedicine @HOMERuN_Network @Pahwa I’m in! I’ll bring the CDI side too. #JHMChat https://t.co/o5sEZuUYDJ
Subha Airan-Javia (she/her) @subhaairan
@michellebr00ks on service this week, mult times i wished there was an effective prob list I could rely on. "how do I make sure everyone who sees this pt will know xyz" unfortunately prob list is also bloated bc its full of billing instead of clinical probs. i think should be separated #JHMChat
Shreya P. Trivedi MD @ShreyaTrivediMD
@MattSakumoto @andrewolsonmd @DrSherineSalib @JHospMedicine @HOMERuN_Network @Pahwa Preach re: collaboration and putting best minds and energies together that can be adopted/adapted locally to peoples EMRs system #JHMchat
Blair Golden @blairgolden
@andrewolsonmd @NdidiUnaka @DrSherineSalib @JHospMedicine Agreed! There's also a time and place for long and thorough notes... I write quite long H&Ps but edit down substantially after admission #JHMChat
Andrew Olson, MD @andrewolsonmd
@MattSakumoto @ShreyaTrivediMD @DrSherineSalib @JHospMedicine @HOMERuN_Network @Pahwa I am SO here for this! Also *why* does everyone I know know everyone else I know? #smallwordamongnerds #JHMChat
Anika Kumar, MD (she/her) @freckledpedidoc
@JHospMedicine A3. In Pediatrics it has because the notes are shared with parents. I don't share adolescent notes to maintain privacy. I also don't share any note for a child with suspected abuse or neglect, or with #mentalhealth concerns. In terms of content, that hasn't changed much #JHMChat
Charlie M. Wray, DO, MS @WrayCharles
@MattSakumoto @andrewolsonmd @ShreyaTrivediMD @DrSherineSalib @JHospMedicine @HOMERuN_Network @Pahwa Great thought, Matt! I think we should: [ ] Add that to our next meeting agenda #JHMChat
Sherine Salib @DrSherineSalib
@MattSakumoto @andrewolsonmd @ShreyaTrivediMD @JHospMedicine @HOMERuN_Network @Pahwa Count me in too! #JHMChat
Vinny Arora MD MAPP @FutureDocs
@MatthewGeorgeMD Which is interesting given issues w billing often requiring those words to justify treatment and stay #jhmchat
Andrew Olson, MD @andrewolsonmd
@gopiastik @MattSakumoto @ShreyaTrivediMD @DrSherineSalib @JHospMedicine @HOMERuN_Network @Pahwa Who feels a workshop coming on??? I do I do! #JHMChat
Dhruv Srinivasachar MD (he/el/ele.) @TheRealDSrini
@freckledpedidoc @JHospMedicine Same case with Newborn notes! "Compromises the privacy of another person" #JHMChat
Journal of Hospital Medicine @JHospMedicine
I am loving these ideas💡. Keep 'em comin! #JHMChat Question 4️⃣ is up in just ✌️ minutes!
Sebastian Suarez, MD, MPH @sebsuarezmd
RT @JHospMedicine: Deleting text from my notes like: #JHMChat https://t.co/ESAOuIFuHy
Subha Airan-Javia (she/her) @subhaairan
@ShreyaTrivediMD @MattSakumoto @andrewolsonmd @DrSherineSalib @JHospMedicine @HOMERuN_Network @Pahwa i am IN!!! I teach about documentation regularly. Previously developed a sim session to teach trainees how to write a day 1 vs day 2 prog note. also important, incorporate tech into documentation teaching. this doesnt happen enough #JHMChat
Jeffrey Shu (he/him) @jawfreyshoe
RT @JHospMedicine: #JHMChat Question ✌️ : #JHMChat Question ✌️ : What drives “note bloat” and how do you fight it?🥊 https://t.co/IGZMqt3O04
Matt Sakumoto @MattSakumoto
@andrewolsonmd @ShreyaTrivediMD @DrSherineSalib @JHospMedicine @HOMERuN_Network @Pahwa #jhmchat https://t.co/WySohjcfLf
Vinny Arora MD MAPP @FutureDocs
@andrewolsonmd @blairgolden @JHospMedicine Honestly it was very resident driven ease of practice type innovation. I don’t know I’ve even thought about it as a coaching opportunity until tonight so thank you! #jhmchat
Society of Hospital Medicine @SocietyHospMed
RT @JHospMedicine: I am loving these ideas💡. Keep 'em comin! #JHMChat Question 4️⃣ is up in just ✌️ minutes!
S. Trent Rosenbloom @trentrosenbloom
@MattSakumoto @andrewolsonmd @ShreyaTrivediMD @DrSherineSalib @JHospMedicine @HOMERuN_Network @Pahwa This was one of the key actions described in the #25x5 output: https://t.co/NtFuxkWhIU #JHMChat
Anika Kumar, MD (she/her) @freckledpedidoc
@JHospMedicine For the reasons listed in the response, I opt out of sharing notes that discuss the following #JHMChat
Andrew Olson, MD @andrewolsonmd
@subhaairan @ShreyaTrivediMD @MattSakumoto @DrSherineSalib @JHospMedicine @HOMERuN_Network @Pahwa Wait wait wait we shouldn't just do what was done in the 70's but now on a computer? #JHMChat
Sherine Salib @DrSherineSalib
@JHospMedicine A3. The 21st Century Cures Act is a good opportunity for us to revisit the language we use in our EMR documentation. IMO, this should have happened a long time ago. It’s the “nothing about me without me” principle. #JHMChat
Mark Shapiro, MD @ETSshow
@WrayCharles @MattSakumoto @andrewolsonmd @ShreyaTrivediMD @DrSherineSalib @JHospMedicine @HOMERuN_Network @Pahwa You should consider inviting @DrJessieAllan to be sure the insight of someone in “non-academic” setting can weigh in. Notes outside of the teaching world are a different sport. I learned that when I became an attending outside of the teaching setting #JHMChat
Blair Golden @blairgolden
@andrewolsonmd @gopiastik @MattSakumoto @ShreyaTrivediMD @DrSherineSalib @JHospMedicine @HOMERuN_Network @Pahwa Love this idea! #JHMChat
Anika Kumar, MD (she/her) @freckledpedidoc
@TheRealDSrini @JHospMedicine Absolutely!! At my institution the notes aren't automatically shared with anyone but the newborn's mother #JHMChat
Journal of Hospital Medicine @JHospMedicine
#JHMChat Question 4️⃣: How do we address burnout associated with documentation requirements? 😩🖥️ ⌨️ https://t.co/eultrCGP5i
Society of Hospital Medicine @SocietyHospMed
RT @JHospMedicine: #JHMChat Question 4️⃣: #JHMChat Question 4️⃣: How do we address burnout associated with documentation requirements? 😩🖥️ ⌨️ https://t.co/eultrCGP5i
Subha Airan-Javia (she/her) @subhaairan
@andrewolsonmd @DocWithBowtie @WrayCharles @MattSakumoto @ShreyaTrivediMD @medrants yaasss!! also, i'm left handed...maybe thats why?!? #JHMChat
Anika Kumar, MD (she/her) @freckledpedidoc
RT @andrewolsonmd: WE HAVE REACHED THE SHOUTY CAPS AMPLIFICATION PORTION OF THE EVENING. SEE THIS TWEET AND REMEMBER IT!!! #JHMChat
Andrew Olson, MD @andrewolsonmd
@ETSshow @WrayCharles @MattSakumoto @ShreyaTrivediMD @DrSherineSalib @JHospMedicine @HOMERuN_Network @Pahwa @DrJessieAllan As usual @ETSshow bringing the wisdom - share more about these differences for us please?? #JHMChat
Andrew Olson, MD @andrewolsonmd
@DrSherineSalib @JHospMedicine AMEN. #JHMChat
Bijay Acharya MD @bijayacharya
@RJmdphilly @JHospMedicine TBH - common (negative) feedback I often receive is I write short notes. In a land of pontificators, I am in the minority. Yet to see hard data that my short notes led to poor outcomes. #jhmchat
Michelle Brooks, MD @michellebr00ks
@subhaairan My least favorite “problem” that I’ve seen - “alteration in comfort.” Not descriptive or additive at all. #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@andrewolsonmd @JHospMedicine i ❤️ this point data 🚫 information #JHMChat
Rebecca Jaffe, MD @RJmdphilly
@WrayCharles @MattSakumoto @andrewolsonmd @ShreyaTrivediMD @DrSherineSalib @JHospMedicine @HOMERuN_Network @Pahwa Also medical universal languages [] to do *** fill in later #jhmchat
Dhruv Srinivasachar MD (he/el/ele.) @TheRealDSrini
@freckledpedidoc @JHospMedicine For ours the notes just aren't released at all...you never know if parent loses custody of the kid or someone else has proxy access...#JHMChat
Wayne H. Liang, MD MS FAMIA FAAP @WayneLiangMD
@JHospMedicine #JHMChat Q3: As a physician I haven’t noticed much difference (for good or ill). As a #caregiver for family members w complex #diseases and language barriers, I am a huge proponent of #opennotes. Being locked out really affects #patient/caregiver understanding of their health.
Robert Centor @medrants
#UncleBob - only changing documentation requirements will matter. This has happened in the outpatient note, yet physicians have not yet changed. Vexing problem. #JHMChat
Michelle Brooks, MD @michellebr00ks
RT @DrSherineSalib: @JHospMedicine A3. The 21st Century Cures Act is a good opportunity for us to revisit the language we use in our EMR documentation. IMO, this should have happened a long time ago. It’s the “nothing about me without me” principle. #JHMChat
Rebecca Jaffe, MD @RJmdphilly
@FutureDocs @MatthewGeorgeMD Ugh agreed. We keep creating impossible systems #jhmchat
S. Trent Rosenbloom @trentrosenbloom
Reducing the documentation burden that contributes to burnout was a key motivator for the #25x5 movement, which is an effort to establish strategies and approaches to reduce clinician documentation burden on US clinicians to 25% by 2025. https://t.co/Z9Y5MEXSMG #JHMChat /1
Anika Kumar, MD (she/her) @freckledpedidoc
@ETSshow @WrayCharles @MattSakumoto @andrewolsonmd @ShreyaTrivediMD @DrSherineSalib @JHospMedicine @HOMERuN_Network @Pahwa @DrJessieAllan Agree. For the newborn patients I care for, the notes are primarily for transition of care to the PCP. #jhmchat.
Andrew Olson, MD @andrewolsonmd
@JHospMedicine Key and important ? Also, though, I wonder how often we blame the system/software when it is in fact a user problem? None of us (or few) learned HOW TO DO THIS THE RIGHT WAY during our formal education and we see the results. #JHMChat
Gopi Astik @gopiastik
@andrewolsonmd @ETSshow @WrayCharles @MattSakumoto @ShreyaTrivediMD @DrSherineSalib @JHospMedicine @HOMERuN_Network @Pahwa @DrJessieAllan I do CDI work in both academic and community-based practices and there ARE similarities and differences. It’s honestly easier IMO in the community because the docs are invested in the metrics and the audience doesn’t change monthly like it does in academics. #JHMChat
Bijay Acharya MD @bijayacharya
@JHospMedicine @jessdreicer We have a "discharge summary prep" vendor that outsources the task but I feel like I end up shortening their summaries even further down. PCP's do not need daily updates. #jhmchat
Sherine Salib @DrSherineSalib
@andrewolsonmd @gopiastik @MattSakumoto @ShreyaTrivediMD @JHospMedicine @HOMERuN_Network @Pahwa Wonderful to see so many others who find the topic of EMR documentation as exciting as I do… I found my people! #JHMChat
Andrew Olson, MD @andrewolsonmd
@RJmdphilly @FutureDocs @MatthewGeorgeMD It's generous to call it a system :) #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@bijayacharya @FutureDocs @andrewolsonmd @JHospMedicine @JenCMyers Heres my take on it Vinny: Discharge summary (most inclusive, but summarized) Handoff (second most, 10k foot view) Daily Note (sea level view) all can stem from the SAME plan iterative plan write it ONCE and not 2-3-4 times. a good wiki and good tech can do this :) #JHMChat
Eileen Barrett MD MPH (she/her) @EileenBarrettNM
@JHospMedicine A1. Communication 🗣! #JHMChat
Mohit Harsh, MD @MohitHarshMD
@JHospMedicine A4: Attendings modeling and providing feedback is key. Need to know how notes can be thorough yet succinct and focusing on how to cut down on note bloat. My old PD sat me down one time and showed me line by line how to improve a discharge summary. Was very formative #JHMChat
Bijay Acharya MD @bijayacharya
@subhaairan @andrewolsonmd @JHospMedicine Yup. We do not need home meds listed on day 12 progress note #jhmchat
Rebecca Jaffe, MD @RJmdphilly
@DrSherineSalib @JHospMedicine What about this tension though? #jhmchat
Vinny Arora MD MAPP @FutureDocs
RT @subhaairan: @bijayacharya @FutureDocs @andrewolsonmd @JHospMedicine @JenCMyers Heres my take on it Vinny: Discharge summary (most inclusive, but summarized) Handoff (second most, 10k foot view) Daily Note (sea level view) all can stem from the SAME plan iterative plan write it ONCE and not 2-3-4 times. a good wiki and good tech can do this :) #JHMChat
Dhruv Srinivasachar MD (he/el/ele.) @TheRealDSrini
@JHospMedicine A4: Not quite at that stage yet, but giving clear instructions on what is relevant, for whom, and how important is the information would be helpful. Also getting billing out of notes please and thank you...#JHMChat #M4A
S. Trent Rosenbloom @trentrosenbloom
Here is an overview of the work produced by stakeholders from across the country with NIH/NLM funding. #25x5 #JHMChat /2 https://t.co/GdbuYEybmO
Journal of Hospital Medicine @JHospMedicine
@bijayacharya @jessdreicer Does that mean someone writes your discharge summary for you? #JHMChat https://t.co/ZGewVOIber
Dhruv Srinivasachar MD (he/el/ele.) @TheRealDSrini
My like button broke from seeing all this fantastic thought tonight! #JHMChat
Andrew Olson, MD @andrewolsonmd
@bijayacharya @subhaairan @JHospMedicine But what if they got 500 ml of 1/2 NS and then 550 ml of NS on HD#4? You don't want to know???? (sarcasm :) #JHMChat
Sebastian Suarez, MD, MPH @sebsuarezmd
@JHospMedicine Teach providers how to write effective notes that require minimal daily editing! e.g. no doses or frequency unless strong reason for it, no words like “yesterday” or “tomorrow” but actual dates #JHMchat
Charlie M. Wray, DO, MS @WrayCharles
@bijayacharya @RJmdphilly @JHospMedicine Yeah, internists really like to think, and talk, and write A LOT, don't they #JHMChat
S. Trent Rosenbloom @trentrosenbloom
I encourage all participants in the #JHMChat to take a look at the materials on the website and help us move forward efficiently to reduce the documentation burden that contributes to burnout. https://t.co/Z9Y5MEXSMG #25x5
Subha Airan-Javia (she/her) @subhaairan
@MattSakumoto @WrayCharles @ETSshow @andrewolsonmd @CatDocMD @JHospMedicine @UCSFIMChiefs I advocate for problem based discharge summaries, with the course summarized by problem. ...sounds like the note.... ...also like a handoff, or off service note... should come from the same content so it is not duplicative #JHMChat
Wayne H. Liang, MD MS FAMIA FAAP @WayneLiangMD
@JHospMedicine #JHMChat Q4 #Burnout is often blamed on the #EHR when much of it is actually #regulatoryburden. Must address root cause—so glad for recent victories there #informaticists/#technologists/#EHR vendors (@EpicResearchOrg , @Cerner etc) should cont to innovate within those bounds
Andrew Olson, MD @andrewolsonmd
@JHospMedicine @bijayacharya @jessdreicer tell me who these people are and how we can find these amazing people. #JHMChat
Charlie M. Wray, DO, MS @WrayCharles
@andrewolsonmd @bijayacharya @subhaairan @JHospMedicine But that 50ml, Andrew! 50ml!!! #JHMChat
Blair Golden @blairgolden
@medrants A4. Agreed with @medrants. I also try to set fair expectations and share best practices re: efficient and effective note writing when I'm on teaching service. #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@DocWithBowtie @JHospMedicine @jessdreicer what i dont love about this, is that it is dupicative with what we are doing in our note, and our handoff, and our prob list they should tie together so you dont have to write the same thing in 5 places #JHMChat
Journal of Hospital Medicine @JHospMedicine
@sebsuarezmd Love these concrete tips #JHMChat
Yichi Zhang (张一弛) @YichiZzzzz
@JHospMedicine A4: I've always treated it as a learning/teaching opportunity but I get that after many years, it inevitably becomes a chore. I maybe naive but fast forward X years, if I have the honor of leading my own team- I hope to keep my upbeat mentality still and pass the energy! #JHMChat
Bijay Acharya MD @bijayacharya
@JHospMedicine I actually like it. I have changed how I write my notes. - no #discriminatory language (still learning) - I clearly documented unknown issues - address nurses' concerns from their notes - clear plan for tomorrow. #jhmchat
Society of Hospital Medicine @SocietyHospMed
RT @YichiZTulane: @JHospMedicine A4: @JHospMedicine A4: I've always treated it as a learning/teaching opportunity but I get that after many years, it inevitably becomes a chore. I maybe naive but fast forward X years, if I have the honor of leading my own team- I hope to keep my upbeat mentality still and pass the energy! #JHMChat
Gopi Astik @gopiastik
@JHospMedicine A4: my CDI hat is on BUT education about documenting for specificity/complexity from the beginning would be HUGE. If everyone understood WHY specificity is needed, it wouldn’t be as burdensome later. Ex: learn not to write “CHF” but always chose acuity & type. #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@andrewolsonmd I STARTED OFF SHOUTING...! is that a problem? 🤪 #JHMChat
Vinny Arora MD MAPP @FutureDocs
@JHospMedicine Make less actually worth more #jhmchat
Society of Hospital Medicine @SocietyHospMed
@YichiZTulane @JHospMedicine We love that attitude! 🙌 #JHMChat
Eileen Barrett MD MPH (she/her) @EileenBarrettNM
@JHospMedicine A2. Overzealous feedback from billers and coders in combination with falsely believing that more is more and that the purpose of the chart is to document everything, rather than what is relevant for communication #JHMChat
Yichi Zhang (张一弛) @YichiZzzzz
@MohitHarshMD @JHospMedicine Yes! Would love more comprehensive instruction on this during IM clerkship! #JHMChat
Joseph “Dr. Joe” Thomas, MD @DocWithBowtie
@JHospMedicine #JHMChat A4: Clinical Documentation Specialists need to be our friends. Honestly, they’re usually just trying to do their job and I find if I work with them cordially, they get me where I need to be. A small part, but that attitude change genuinely helps.
Rebecca Jaffe, MD @RJmdphilly
@subhaairan @bijayacharya @FutureDocs @andrewolsonmd @JHospMedicine @JenCMyers Add to that a daily dc plan summary and shared task list to share with CM/SW and you can have my first born #jhmchat
Subha Airan-Javia (she/her) @subhaairan
@RJmdphilly @blairgolden @JHospMedicine i'm game #WriteItOnce #JHMChat @CareAlignAI
Matthew George, MD @MatthewGeorgeMD
@JHospMedicine #JHMchat the only way is to simplify and incentive. If hospital cdi wants us to document certain way, then give me carrot for doing so
Society of Hospital Medicine @SocietyHospMed
Thank you for being a part of this #JHMChat. 🙏 As we wind down, please take some time to fill out our brief feedback form. 📝 We want to 👂 from you on topics of interest and how we can continue to improve #JHMChat! 👀 https://t.co/k9nukavP9F
Journal of Hospital Medicine @JHospMedicine
Wow, this #JHMChat was 🔥! Thanks for the great discussion! Only a few minutes left ⌚ . What's been your biggest take away? 🤓
Andrew Olson, MD @andrewolsonmd
@EileenBarrettNM @JHospMedicine Super important point here - wonder how the fantastic @gopiastik collaborates with her CDI team to rein this in? #JHMChat
Wayne H. Liang, MD MS FAMIA FAAP @WayneLiangMD
@JHospMedicine @EpicResearchOrg @Cerner …and hospital leaders should lead the charge in reducing #notebloat, unnecessary documentation (contributors of burnout) when it’s longer requires. Org Culture/behavior change is hard and it’s easy to fall back into maladaptive old habits. #JHMChat #burnout
Eileen Barrett MD MPH (she/her) @EileenBarrettNM
@WrayCharles @DocWithBowtie @JHospMedicine ^I take immense pleasure in deleting all the old, resolved abnormal lab findings #JHMChat
Mohit Harsh, MD @MohitHarshMD
Essentially my philosophy on medicine #Zenternist #JHMChat
Leonor Fernández, MD @lfernandezi
@RJmdphilly @FutureDocs @MatthewGeorgeMD #JHMChat one could envision a smart system that would on the patient side of the portal explicate/translate those terms
Charlie M. Wray, DO, MS @WrayCharles
@bijayacharya @JHospMedicine @jessdreicer Interesting. I presume there's a decent ROI here. Suspect they'd have some billing acumen and be able to pull that info out better than an overworked MD/DO - and allows MD/DO to focus on patient care...?? #JHMChat
Michelle Brooks, MD @michellebr00ks
RT @FutureDocs: @JHospMedicine Make less actually worth more #jhmchat
Dhruv Srinivasachar MD (he/el/ele.) @TheRealDSrini
@DocWithBowtie @JHospMedicine @jessdreicer We have the same in our version...Peds uses it decent bit, but everybody still ends up putting in the DC summary template instead of the hospital course and ruining everything...#JHMChat
Subha Airan-Javia (she/her) @subhaairan
@bijayacharya @JHospMedicine @LannaFelde @MGHMedicine @CareAlignAI @JHMTIC whaaaat? thanks and that is awesome!! would love to chat about it! if you cant tell, i live, breathe, think and dream about how to make documentation and clinical workflow better 😂😂 #JHMChat
Anika Kumar, MD (she/her) @freckledpedidoc
@JHospMedicine A4. I think what has come up in this #jhmchat is a discussion on the not's audience. The Cures Act was meant to make the audience be the patient. #covid threw a 🔧 in that. However, until we reconcile the note's audience there will continue to be #Burnout #JHMChat
Andrew Olson, MD @andrewolsonmd
@RJmdphilly @subhaairan @bijayacharya @FutureDocs @JHospMedicine @JenCMyers I'll pitch in a kid too! #JHMChat
Journal of Hospital Medicine @JHospMedicine
Don't know about you all but I feel inspired to teach my residents about documentation #jhmchat https://t.co/AyVykBxYu7
Bijay Acharya MD @bijayacharya
@JHospMedicine Reduce problems on A/P. A pt with heart failure exacerbation should not have - shortness of breath - weight gain - hypoxia - CHF as separate problems. - Change diagnosis from symptoms to specific disease code as more information comes up. Helps with billing. #jhmchat
Rebecca Jaffe, MD @RJmdphilly
A4 just a balancing thought - agree with the goal to reduce needless documentation, but need to preserve the good things - time to think and a cognitive scaffolding for difficult work. Can’t just take that time and say “go hum I guess you can see 5 more patients today” #JHMChat
Journal of Hospital Medicine @JHospMedicine
That's a wrap folks. 🎬 Great having you all at this #JHMChat and we hope you'll join us for the next one! Huge thanks to our special guests 👏 👏 👏 👩‍⚕️@blairgolden 👨‍⚕️@medrants 👨‍⚕️@andrewolsonmd I've been your #JHMChat moderator 🎙️ @LannaFelde. Goodnight 🙋!
Wendy Simon @drwendysimon
@JHospMedicine A1. To document the A/P for the day/stay and my clinical reasoning for other members of the care team and posterity. Process of writing helps me think and ensure I’ve addressed everything. I give a lot of specific feedback and explain rationale to help care and workflow. #JHMchat
Subha Airan-Javia (she/her) @subhaairan
@michellebr00ks @JHospMedicine so many things bother me about the limitations of EHR problem lists cant drag and drop to reorder cant separate billing probs from clinical probs etc etc #JHMChat
Robert Centor @medrants
#UncleBob - thanks for inviting me may all your notes be short and meaningful #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@bijayacharya @JHospMedicine I think you and I writing from the same script ;) #JHMChat
Darcy Wooten she/her @Darcy_ID_doc
@JHospMedicine A3: I’ve used it to write encouraging messages to my patients (“doing great with ART! Virologically suppresses!”) but I haven’t gotten feedback nor do I know if it’s effective. #JHMchat
Vignesh Doraiswamy, MD @DoctorVig
So sad to miss @JHospMedicine 's #JHMChat today given how much I love the chats in general but especially given todays topic. Folks who work with me know that I love to make sure our documentation is value added to everyone involved in the care of the pt (including the pt!!)
Dhruv Srinivasachar MD (he/el/ele.) @TheRealDSrini
@JHospMedicine Biggest Take Away: We need a national curriculum for clinical documentation. This includes what should be in a progress note, documenting significant events, and how to create a non-bloated but complete discharge summary. #JHMChat
Andrew Olson, MD @andrewolsonmd
Gonna print this one out and frame it. #JHMChat
Matthew George, MD @MatthewGeorgeMD
Great discussion everyone. However much work left to do #JHMChat
Mohit Harsh, MD @MohitHarshMD
RT @medrants: #UncleBob opines on Q2 note bloat comes from presumed billing requirements and the ease of importing the data no one would actually type all that information #JHMChat
Society of Hospital Medicine @SocietyHospMed
RT @TheRealDSrini: @JHospMedicine Biggest Take Away: @JHospMedicine Biggest Take Away: We need a national curriculum for clinical documentation. This includes what should be in a progress note, documenting significant events, and how to create a non-bloated but complete discharge summary. #JHMChat
Blair Golden @blairgolden
@subhaairan @RJmdphilly @JHospMedicine @CareAlignAI This is a movement I can get behind! #jhmchat
Mohit Harsh, MD @MohitHarshMD
RT @medrants: That was exactly the original idea of the SOAP note. We included the hx (S) and physical/labs/images (O) relevant to that problem #JHMChat
Society of Hospital Medicine @SocietyHospMed
@medrants Thanks for your wisdom! #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@ericschul @JHospMedicine I am currently researching how we use these words in clinical documentation.....stay tuned! #JHMChat
Wayne H. Liang, MD MS FAMIA FAAP @WayneLiangMD
@subhaairan @bijayacharya @FutureDocs @andrewolsonmd @JHospMedicine @JenCMyers *snap snap SNAP SNAP SNAP*😄 Love the #writeitonce principle of #clinicalnotes for #handoffs and #dcsummary! #JHMChat
Anika Kumar, MD (she/her) @freckledpedidoc
@JHospMedicine @blairgolden @medrants @andrewolsonmd @LannaFelde Thanks for another great #JHMChat.
Rachel Johnson @DoubleDawgMD
RT @medrants: #UncleBob - thanks for inviting me may all your notes be short and meaningful #JHMChat
Rebecca Jaffe, MD @RJmdphilly
@Darcy_ID_doc @JHospMedicine Lots of exclamation points :) #jhmchat https://t.co/9kfjTsm5GW
Society of Hospital Medicine @SocietyHospMed
That’s a wrap on February’s #JHMChat with @blairgolden, @medrants, and @andrewolsonmd. Many thanks to them for this enlightening and fun conversation. 🙌 🎉 Shout out to @LannaFelde for facilitating as @JHospMedicine. See you all next month!
Wayne H. Liang, MD MS FAMIA FAAP @WayneLiangMD
RT @medrants: #UncleBob - thanks for inviting me may all your notes be short and meaningful #JHMChat
Eileen Barrett MD MPH (she/her) @EileenBarrettNM
@JHospMedicine A2. Under utilization of time based billing is a real issue, too #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@andrewolsonmd @WrayCharles @ETSshow @CatDocMD @JHospMedicine @UCSFIMChiefs how about flagging parts of your existing plan as "to do" items and "discharge" items...so that you dont have to write them again? #WriteItOnce @CareAlignAI #JHMChat
S. Trent Rosenbloom @trentrosenbloom
RT @Darcy_ID_doc: @JHospMedicine A3: @JHospMedicine A3: I’ve used it to write encouraging messages to my patients (“doing great with ART! Virologically suppresses!”) but I haven’t gotten feedback nor do I know if it’s effective. #JHMchat
Gopi Astik @gopiastik
@andrewolsonmd @EileenBarrettNM @JHospMedicine Id say you should get credit for work. If you replaced K, document hypokalemia. You saw, recognized & treated it. The hospital should get credit for it. I often share the monetary difference it can make. Controversial, yes. But it explains the value of the specificity. #JHMChat
Yichi Zhang (张一弛) @YichiZzzzz
@JHospMedicine @blairgolden @medrants @andrewolsonmd @LannaFelde Thank you @JHospMedicine and @LannaFelde for organizing another cool #JHMChat gettogether! And see y'all next month! https://t.co/5FQJ5plfay
Michelle Brooks, MD @michellebr00ks
Great job @LannaFelde!! 🔥🔥🔥 #JHMChat https://t.co/KtGqsiapwr
Gopi Astik @gopiastik
@sebsuarezmd @JHospMedicine I wish EPIC wouldn’t let you sign a note with any of these words in it. #dreams #JHMChat
Eileen Barrett MD MPH (she/her) @EileenBarrettNM
@gopiastik @andrewolsonmd @JHospMedicine Definitely, but delete it as soon as it’s addressed #JHMChat
Dhruv Srinivasachar MD (he/el/ele.) @TheRealDSrini
@medrants Thanks #UncleBob! #JHMChat
Subha Airan-Javia (she/her) @subhaairan
RT @WayneLiangMD: @subhaairan @bijayacharya @FutureDocs @andrewolsonmd @JHospMedicine @JenCMyers *snap snap SNAP SNAP SNAP*😄 Love the #writeitonce principle of #clinicalnotes for #handoffs and #dcsummary! #JHMChat
Journal of Hospital Medicine @JHospMedicine
@michellebr00ks @LannaFelde Thank you my digital media sister 💁‍♀️#jhmchat
Anika Kumar, MD (she/her) @freckledpedidoc
@RJmdphilly @andrewolsonmd @ShreyaTrivediMD @DrSherineSalib @JHospMedicine #JHMChat https://t.co/ieAJdURaBF
Gopi Astik @gopiastik
@EileenBarrettNM @andrewolsonmd @JHospMedicine Yes one of our acronyms we teach is PEARLS. The R = resolved. Once the sepsis, pneumonia, AKI is done, call it resolved & remove from the A/P the next day. Conditions that just disappear confuse the coders so don’t just delete it - say it’s resolved and delete next day. #JHMChat
Joseph “Dr. Joe” Thomas, MD @DocWithBowtie
@JHospMedicine @blairgolden @medrants @andrewolsonmd @LannaFelde Great chat! #JHMChat Thanks, all!
Sherine Salib @DrSherineSalib
RT @DrSherineSalib: @JHospMedicine A1. As a #MedEd community, we are not intentional enough about teaching documentation skills. We assume that it’s a skill that learners can pick up.. We need a “clinical documentation curriculum”. After all, this is a huge part of what physicians do every day. #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@andrewolsonmd @gopiastik @MattSakumoto @ShreyaTrivediMD @DrSherineSalib @JHospMedicine @HOMERuN_Network @Pahwa yes!!!!! #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@JHospMedicine can't keep up!! so much great content!! #JHMChat https://t.co/L6uqoazLWh
Bijay Acharya MD @bijayacharya
@WrayCharles @JHospMedicine @jessdreicer Yes. Esp on our complex patients, it is super helpful. They are to the point and succint. Feedback is quickly incorporated and you can see the change. #jhmchat
Mark Shapiro, MD @ETSshow
@andrewolsonmd @WrayCharles @MattSakumoto @ShreyaTrivediMD @DrSherineSalib @JHospMedicine @HOMERuN_Network @Pahwa @DrJessieAllan Brevity. Right info in right place at right time Also, the note is 3rd order comms tool. 1st order: face to face 2nd order: phone/secure text (this is BY FAR most common way we communicate 3rd order: note. When I call/text you w/ ? do not ask me if I read your note #JHMChat
Mark Shapiro, MD @ETSshow
RT @andrewolsonmd: @ETSshow @WrayCharles @MattSakumoto @ShreyaTrivediMD @DrSherineSalib @JHospMedicine @HOMERuN_Network @Pahwa @DrJessieAllan As usual @ETSshow bringing the wisdom - share more about these differences for us please?? #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@andrewolsonmd @ShreyaTrivediMD @MattSakumoto @DrSherineSalib @JHospMedicine @HOMERuN_Network @Pahwa EHRs are digital recreations of analog charts, instead of truly leveraging what tech can do. fine for a first iteration, but we need to revamp! #JHMChat #clinicalinformatics
Mark Shapiro, MD @ETSshow
@Darcy_ID_doc @JHospMedicine Love this! #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@bijayacharya @RJmdphilly @JHospMedicine this would be interesting....want to study it?? i have a lab! assuming in your short notes you also write your clinical reasoning? #JHMChat
Bijay Acharya MD @bijayacharya
@JHospMedicine @jessdreicer Yes. A vendor that has #doctors in #India. Place an order in #ehr. d/c summary done overnight. It needs fine tuning but is 90-95% good. really helps for complex patients with long length of stay. #jhmchat
Subha Airan-Javia (she/her) @subhaairan
@michellebr00ks @WrayCharles @andrewolsonmd @bijayacharya @JHospMedicine I routinely say "you realize that 1L of IVF is basically a few 12 oz cans of liquid, right???" #JHMChat
Mark Shapiro, MD @ETSshow
RT @DrSherineSalib: @JHospMedicine A1. As a #MedEd community, we are not intentional enough about teaching documentation skills. We assume that it’s a skill that learners can pick up.. We need a “clinical documentation curriculum”. After all, this is a huge part of what physicians do every day. #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@medrants i think change requirements but also TECH systems can be designed better! #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@ETSshow @Darcy_ID_doc @JHospMedicine this is the BEST! #JHMChat
Mark Shapiro, MD @ETSshow
@JHospMedicine @blairgolden @medrants @andrewolsonmd @LannaFelde Fantastic chat! Well done all around & thank you! #JHMChat
Bijay Acharya MD @bijayacharya
@WayneLiangMD @subhaairan @FutureDocs @andrewolsonmd @JHospMedicine @JenCMyers Yes. #writeitonce would change our lives. I think the bloat is also bcoz it is hard to accumulate/search relevant data points. Search for #aspirin on #EPICehr & you will get results that doesn't make any sense. We used to have @QPIDHealth search engine that I miss #jhmchat
Subha Airan-Javia (she/her) @subhaairan
@bijayacharya @JHospMedicine @jessdreicer that is interesting. i feel like so much needs to come from the clinical reasoning. also, it should be able to come from what we've already written...and not need to be an entirely separate, duplicative effort. we do need to summarize content, but should be iterative.#JHMChat
Subha Airan-Javia (she/her) @subhaairan
@templeratcliffe @andrewolsonmd @SocietyHospMed @blairgolden @medrants @LannaFelde @JHospMedicine agree! i picked it up in chapel hill (#Tarheel) Thank you for a wonderful conversation! #JHMChat
Subha Airan-Javia (she/her) @subhaairan
RT @blairgolden: @subhaairan @RJmdphilly @JHospMedicine @CareAlignAI This is a movement I can get behind! #jhmchat
Subha Airan-Javia (she/her) @subhaairan
@bijayacharya @JHospMedicine #JHMChat https://t.co/PkqkfEWGyM
Wendy Simon @drwendysimon
@JHospMedicine A4. Shorter, query-proof notes take less energy to proofread/update every day and prevent the CDI queries that irk me #JHMchat
Bijay Acharya MD @bijayacharya
@subhaairan @RJmdphilly @JHospMedicine Yes. I don't download the whole uptodate ddx. Tricky part is to define what constitutes "short". #jhmchat
Subha Airan-Javia (she/her) @subhaairan
@bijayacharya @JHospMedicine absolutely! surprise surprise, i am also a LUMPER (not a splitter) of problems my teaching: if the plan is the same, it should be part of the same problem! #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@andrewolsonmd @RJmdphilly @bijayacharya @FutureDocs @JHospMedicine @JenCMyers um, i hate to keep doing this but that is LITERALLY what we built into @CareAlignAI took 15 years, and 3 iterations of completely different user interfaces and workflows, but I finally got there! #JHMChat
Subha Airan-Javia (she/her) @subhaairan
RT @RJmdphilly: @subhaairan @blairgolden @JHospMedicine #writeitonce should be a movement #jhmchat
Subha Airan-Javia (she/her) @subhaairan
@trentrosenbloom ditto! it was SUCH a great conference with so much useful content! #JHMChat #25x5
Wendy Simon @drwendysimon
@JHospMedicine A3. Honestly it hasn’t. And patients/families ask me much more frequently about random non-clinically significant lab values outside the reference range than they do about the notes. Still do patient-targeted documentation in dc instructions not the notes #JHMchat
Wayne H. Liang, MD MS FAMIA FAAP @WayneLiangMD
RT @trentrosenbloom: Here is an overview of the work produced by stakeholders from across the country with NIH/NLM funding. #25x5 #JHMChat /2 https://t.co/GdbuYEybmO
Subha Airan-Javia (she/her) @subhaairan
@JHospMedicine @CatDocMD @WrayCharles @michellebr00ks @NdidiUnaka Happy to help! #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@bijayacharya @andrewolsonmd @YichiZTulane @JHospMedicine Yes. but how archive instead of delete? in *some* situations, it can be helpful to know what was on the original ddx... key is it has to be easily accessible, but out of the way. #JHMChat
Subha Airan-Javia (she/her) @subhaairan
@andrewolsonmd @JHospMedicine um. have another hour? this vid prob sums it up best, but in sum: wiki that has the components of a SOAP note, w/ prob based plan. semi-structured with filters/views, to pull out daily note, FYIs, handoffs, tasks, on call items, dispo items..more! https://t.co/QPi5SPlO0a #JHMChat
Society of Hospital Medicine @SocietyHospMed
If you attended tonight’s #JHMChat we want to hear from YOU! Please take a few moments to fill out our very brief feedback form. 📝 What topics do you want to see in upcoming months? 🏥 How can we continue improving #JHMChat? 👀 https://t.co/k9nukavP9F
Subha Airan-Javia (she/her) @subhaairan
@bijayacharya @andrewolsonmd @YichiZTulane @JHospMedicine sounds awesome! looking forward to chatting! Another #JHMChat connection for the win!
Mark Shapiro, MD @ETSshow
RT @subhaairan: @andrewolsonmd @JHospMedicine um. have another hour? this vid prob sums it up best, but in sum: wiki that has the components of a SOAP note, w/ prob based plan. semi-structured with filters/views, to pull out daily note, FYIs, handoffs, tasks, on call items, dispo items..more! https://t.co/QPi5SPlO0a #JHMChat
vumcDBMI @vumcdbmi
RT @trentrosenbloom: Here is an overview of the work produced by stakeholders from across the country with NIH/NLM funding. #25x5 #JHMChat /2 https://t.co/GdbuYEybmO
Jessie Allan, MD @DrJessieAllan
The irony of missing #JHMChat on notes because you are still at the hospital charting…sigh 🤦‍♀️ Looking forward to reading all these tips tomorrow! 📝
Mark Shapiro, MD @ETSshow
@MorganSLevy @DrSherineSalib @JHospMedicine That’s a great mindset & goal. Will serve you well for rest of your career #JHMChat
Paul Shaniuk @PShaniuk
RT @JHospMedicine: #JHMChat Question 1️⃣ : #JHMChat Question 1️⃣ : What do you consider the primary purpose of your notes? How do you teach students and residents about best practices in documentation? 📝 https://t.co/rX9pwNYwjy
Subha Airan-Javia (she/her) @subhaairan
@andrewolsonmd @DocWithBowtie @WrayCharles @MattSakumoto @ShreyaTrivediMD @medrants thinking about the arrow direction... i think i put the arrows to the left bc: 1-I want to see the value immediately next to the label w/o having to move my eyes to the end of line (#lazy!) 2-its easier to type w/o having to move mouse to the end of the line (#lazy!) #JHMChat
#JHMChat content from Twitter.