(Circulation. 1999;100:1461.)
© 1999 American Heart Association, Inc.
Correspondence |
Documentation for the Sake of Documentation?
San Pedro Medical Clinic San Antonio, Tex
 |
Introduction |
|---|
 Top Introduction ReferencesIntroduction References |
|---|
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.
|
References |
|---|
|
TopIntroductionReferencesIntroduction References |
|---|
-
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.
[Abstract/Free Full Text]
Response
Section of Preventive Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio
Case Western Reserve School of Medicine
Department of Family Medicine, Case Western Reserve School of Medicine, Cleveland, Ohio
|
Introduction |
|---|
|
TopIntroductionReferencesIntroduction References |
|---|
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.1 2 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.3 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.4 Unfortunately, many
patients report that their caregivers have never urged them to quit
smoking.5 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.
|
References |
|---|
|
TopIntroductionReferencesIntroduction References |
|---|
-
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.
-
McGinnis J, Foege W. Actual causes of death in the
United States. JAMA. 1993;270:2207–2212.[Abstract]
-
Fiore M, Bailey W, Cohen S. Smoking Cessation:
Clinical Practice Guideline. Peterborough, UK: Diane Publishing;
1996.
-
Ockene, J Kristell J, Golberg R, Ockene I, Merriam P,
Barrett S, Pekow P, Hosmer D, Gianelly R. Smoking cessation and
severity of disease: the Coronary Artery Smoking Intervention
Study. Health Psychol. 1992;11:119–126.[Medline]
[Order article via Infotrieve]
-
Goldstein M., Niaura R, Willey-Lessne C, DePue J,
Eaton C, Rakowski W, Dube C. Physicians counseling smokers. Arch
Intern Med. 1997;157:1313–1319.[Abstract]
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||