Documentation for the Sake of Documentation?
To the Editor:
In their recent study, Frolkis and colleagues1 attempt to determine by chart review how often patients with acute myocardial infarction are counseled to quit smoking and encouraged to exercise. They acknowledge that if no such counseling nor encouragement is documented in the chart, the study assumes none was done.
Certainly a patient hospitalized with an acute infarction is unusually likely to be amenable to the idea of quitting smoking and ought to be so encouraged. But many patients are still not interested in quitting. In those cases, most doctors probably do not document a fruitless attempt at counseling in the chart. Why commemorate a waste of breath with a waste of ink? Frolkis and colleagues suggest doing the documentation if only to placate chart reviewers and defense lawyers.
Physician time and patience are finite resources. Suggesting that a patient quit smoking and getting the brush-off from that patient is a bit trying. Having in addition to write in a chart, “Counseled patient to quit smoking, but compliance doubtful,” is considerably more trying on a doctor’s patience. Furthermore, a cursory comment about smoking and lifestyle changes, made mainly to justify a chart entry that “covers” the doctor, is very unlikely to leave a patient with any useful motivation.
The idea that “If it’s not documented in the chart, it wasn’t done,” speaks volumes about anyone who subscribes to it.
- Copyright © 1999 by American Heart Association
Frolkis JP, Zyzanski SJ, Schwartz JM, Suhan PS. Physician noncompliance with the 1993 National Cholesterol Education Program (NCEP-ATPII) guidelines. Circulation. 1998;98:851–855.
We were pleased that Dr Grant acknowledges the importance of counseling high-risk patients to quit smoking cigarettes but were puzzled by the intensity of his objection to documenting such an effort. The use of cigarettes represents the largest preventable cause of mortality and health-related expenditure in the United States, accounting for ≈400 000 deaths yearly.R1 R2 The data are clear that even brief interventions by physicians and other healthcare professionals can significantly increase quit rates and that the documentation of current tobacco use is a key element of any successful cessation program.R3 Interventions targeted to hospitalized patients have reported major impact, presumably because patients may be more receptive to suggestions regarding lifestyle change in the setting of an acute event or procedure.R4 Unfortunately, many patients report that their caregivers have never urged them to quit smoking.R5
In addition, as we report, there is good evidence that what is recorded in the hospital record is an accurate reflection of actual physician behavior, so the conclusion that “most doctors probably do not document a fruitless attempt at counseling in the chart” must be viewed with caution. Moreover, we are not encouraging documentation “to placate chart reviewers and defense lawyers,” as Dr Grant states; we are merely reporting the reality of the ways chart notes can be used.
Less clear is what Dr Grant finds so different about documenting advice to discontinue cigarette use from the many other suggestions physicians offer and routinely record in the hospital or office chart. Advising patients to lose weight, increase exercise, reduce alcohol consumption, wear seat belts, practice safe sex, or get yearly mammograms, as well as documenting such advice, provides key information for our own future use or for those colleagues who may encounter our patients at another time or in another setting. Because most patients who eventually quit cigarettes successfully have tried and failed previously, noting one’s effort to help patients with this complicated and sometimes painful process can provide both patient and physician with a useful marker of their joint progress. We are not advocates of defensive medicine or creating unnecessary paperwork. Our concern is that physicians underutilize their considerable influence in helping patients adopt the healthier lifestyles that could decrease the burden of heart disease.
US Department of Health and Human Services. The Health Consequences of Smoking: Nicotine Addiction: A Report of the Surgeon General. Rockville, Md: US Dept of Health and Human Services, Public Health Service, Centers for Disease Control; 1988. DHHS publication (CDC) 88–8406.
Fiore M, Bailey W, Cohen S. Smoking Cessation: Clinical Practice Guideline. Peterborough, UK: Diane Publishing; 1996.