During one of the pilot studies for the CAMP Method CDI Training studies, a group of 16 physicians at a suburban Philadelphia hospital agreed to be ginea pigs for the program design. As a first step, I asked them to take the pre-test, which would rate their pre-existing knowledge of clinical documentation. At one point, I noticed pained looks on the faces of most of the physicians.
Their fingers running wildly through their hair, the physicians were taking well over the 15 minutes I had alloted for the pre-test. The average score on the pre-test was 63 percent, but it was one question in particular that drove them to the brink of madness: "A patient is admitted for cardiac catheterization to rule out suspected CAD. The patient has a history of CHF and needs to be placed on Lasix. Document the order for Lasix for this patient."
As it turned out, the issue for the physicians was how to document the amount of lasix when they did not have key information about the patient like weight, electrolyte levels, etc. Many of them guessed. Others documented with painstaking detail the different doses of Lasix depending on weight. Interestingly, although the physicians documented detailed information for this order, not one physician found it necessary to state that they were ordering the Lasix for CHF. When we addressed this during the training session, they all looked both shocked and relieved simultaneously.
It was like a light bulb went on in their heads.....of course, we should document that the Lasix is for CHF! Hopefully the EHR will result in greater compliance with these types of documentation challenges. But in the meantime, it's important not to assume that your physicians know the simple stuff. In fact, if our pilot is representative of most physicians, they are more likely to painstakingly focus on the difficult and overlook the simple.
