Updated on: July 17, 2019

Roadkill as Documentation

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Original story posted on: July 15, 2019

All bad documentation is based on lies – the lies doctors (and all human beings) tell themselves.

We always believe our lies, because they are how we construct a false reality that makes our bad behavior seem acceptable to ourselves. Theologians might call it original sin, humanists might call it human nature, and psychologists might call it our limbic system gone bad. Children might say they don’t know why they did it. In this respect we are all still kids.

The answer to the question of why trashy documentation persists is that outside of the clinical documentation improvement (CDI)/documentation industrial complex, few really care about it. Doctors don’t, administrators don’t, electronic medical record (EMR) vendors don’t – this issue has had so much lip service paid to it that we can see teeth even when mouths are closed. Bad documentation has survived all efforts of “documentation improvement,” to the point of defeating it. Like the apocryphal story about cockroaches and nuclear Armageddon, mediocre documentation has survived all-out administrative thermonuclear war by the organized forces of CDI. 

Perhaps you don’t think we lie our way into inadequate documentation?

Consider this: the same physician who claims that an electronic mountain of chart trash piled high in the EMR will protect them from a lawsuit piles the same chart trash up each day – and you do not need a medical degree to know that repetition isn’t documentation.

In truth, we accept bad documentation much the same way as we accept refractory bad manners from our relatives. We complain, we plead, but we accept what we cannot change. Doctors know that pleas for better documentation are just innocuous nagging. Only we naggers imagine that without any evidence of change, we are being effective. Physicians can delude themselves into believing they are writing meaningful notes; we can delude ourselves into believing that our CDI efforts are not meaningless.

So we are left with the following choices, in light of the fact that documentation is bloating for exactly the same reason the bellies of roadkill victims bloat:

  1. Documentation isn’t as important as we think
  2. Documentation improvement isn’t as effective as we imagine
  3. Reason hasn’t and cannot solve this problem
  4. The SOAP note now enables swollen notes

The paradigm has shifted – or, in my opinion, it never existed. Ideal notes are rare, not common. Really good notes are not only rare but when found, they are pithy and cogent. Intelligent notes are concise; bloated notes are unintelligible.

Documentation in its present form cannot be fixed – it has been perennially broken and now is just overinflated. It needs to be deflated and made simple:

  1. Why does the patient need to be in the hospital
  2. What is being done to fix this
  3. Why can’t they be discharged

Imagine documenting all of what’s wrong about bad documentation. We are all doing something wrong, to include those of us who are bloating notes and those of us who have been trying to let the gas out of bloated notes. Documentation improvement is a failure. We do not need more vain efforts to fix what has proven to be an insoluble problem – they are Gordian notes.

Our complicated efforts at reforming bad notes has only led to bloated ones. The antidote to bloat is simple: why is the patient here, what are we doing to them, and why can’t they leave.

We treat the poor notes that are offered as documentation and the poor creatures that are offed as roadkill the same – we ignore them, and drive around them. 

We need to stop putting roadkill in our charts.


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Michael A. Salvatore, MD, FACP

Dr. Michael Salvatore was a pulmonary medicine/critical care physician for 35 years. Since 2012 he has been the physician advisor and medical director of the palliative care team at Beebe Healthcare in Delaware. After earning his MD at the University of Arizona, he trained in internal medicine and PULM/CCM at Duke University. Dr. Salvatore is a member of the RACmonitor editorial board.

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