Lessons in Supportive Care, VIII: Having the Chart Support Your Goals, and Remind You to Ask About Palliative Care
By R. Brian Mitchell, MD and Thomas J. Smith, MD, FACP
Point 1: One of our hopes is that if we ever go to jail, it will be for something that we believe in or was great fun. Not for Medicare fraud.
Point 2: ". . . the immediate needs of the patient make it difficult for the physician to tell him frankly that medical science does not yet possess a cure for his disease. . . . The desire to help will encourage the physician to "try something" ...a tendency toward autistic thinking that is alien to the engineer." Eugene Bleuler, Autistic Undisciplined Thinking in Medicine, (and how to overcome it), 1919.
We just got the most recent series of five-page, small print regulations from our business managers telling us how to chart so that we fit all Medicare regulations, past, present, and future (see Point 1). It was intelligible to someone, somewhere, but not to us. Or, maybe, we are just resistant to dividing the mouth into four quadrants for examination and documentation.
Call us old-fashioned, but we think the chart should serve us and not the other way around. It’s fine if it documents billable services, but its main purpose is to provide a record of what we’ve done, what has gone on, and help us plan a realistic future (see Point 2). This application of engineering to cancer treatmentat least the principles of measuring what you do and recording itseems sound. It can be embarrassing to suggest "that new drug, vinorelbine" to a patient and have them remind you it didn’t work three months ago; information can be hard to find sometimes on old-fashioned charts.
What should the chart have?
Surprisingly, there has been little published information about what should be in the chart or how it should be organized. In the interest of empiric improvement, here is what we have used in our rural cancer outreach program and our own practices. It works for us. (See special supplement inserted in this issue).
How can you get the information?
From any computer. Imagine being in one office, and being able to get all this "stuff" (see supplement) without leaving your seat, quickly, cheaply, and easily. No faxing or shuffling to try to find chest radiograph reports or mammograms from 1993; the results are all in one place.
How do you set something like this up?
You hire someone, unless you are an amateur programmer. There are commercially available programs out there, but they seem to be more interested in documentation for billing than in patient decision making.
This program runs on WordPerfect for Windows, using sophisticated macros. They are hard to set up but not to use. Anyone who can use WordPerfect can use this.
One nice touch is that the list stays up-to-date in each category. Since you work from the same template, you add things to what is already there rather than create a new note each time.
The best thing is how easy it is to make changes. You can write on an old template or set up a new blank template for someone else to type, dictate it by section, or type it yourself. And, you can take the templates to a quiet spot, crack open a cold one, and dictate in peace and quiet.
Why is this so different?
OK, so it still looks like a regular medical record but there’s more in there.
It directly lists the most common source of errors: medications.
It directly lists the goals of treatment. In our experience, we only think about this if reminded. It is too easy to treat with curative-type toxicities for only a small benefit. If we list the goal of treatment, we can remind ourself to check it regularly. As Arthur Frank, a medical sociologist being treated for testicular cancer, pointed out, it is easy for both the patient and doctor to get "burned out" and forget to question whether treatment is helping.
It directly addresses Resuscitation Status. Like most of the doctors in the SUPPORT study, we fail to address this until a few days before death, or not even then. Having this entry as a "goad" to make us address this is helpful to our practice. Having advance directives in place won’t save money, but it might help tailor the treatment to what the patient wants. And it might prevent "Oh, doctor, if I’d only known I had such a short time to live, I would have lived these last two months so differently!"
Improving care by a thorough review of systems
The quality improvement process should include getting the most from each visit. We see a lot of patients with solid tumors. It may be just the advanced age of some of us, but unless we have a "cheat sheet," we are less likely to ask all the important questions.
For instance, for breast cancer patients, doctors too rarely ask about these things of importance:
• "How are you coping with the illness?"
• "How are you coping with the treatment?"
• "Problems with hot flashes?"
• "Any sexual problems, like vaginal dryness or painful intercourse or lessened libido?"
• "Are you doing breast self exam? Would you like teaching on technique?"
• "People with breast cancer are at increased risk for other cancers. Have you had screening tests for colon and GYN cancers?"
Now, we can write them down, and have them to ask for each breast cancer patient. And, we will know what the answers were last time, what medications they were on, etc. It would be nice to know if we tried megestrol acetate for hot flashes in the past, for instance.
One of the beauties of this system is that it lets you document what you said. We all have (or should have) scripts of important messages. Having them in a handy list a) reminds you to discuss them, and b) documents that you did. It facilitates patient education, as shown on the checklist. (See checklist, page 15.)
Using this for billing?
One of the hallmarks of successful billing is documentation. If it is not written, it’s not reimbursable, we guess. One beauty of this record is that it folds nicely into a billing system. If we get audited, chances are that we can prove we asked the questions, listened for the answers, thought about a complex series of concerns, and made tough decisions, including telling the patient what to do. Mom and Apple Pie.
Take home message
The chart should serve you, your patient, and the others on the team. A simple narrative paragraph does not give enough information (and may not satisfy new billing documentation hurdles). A simple design change with attention to what we do well, and what we should do better, makes the chart a much better document.
R. Brian Mitchell MD designed this template. He can be reached at firstname.lastname@example.org, (804)379-4997. (Dr. Mitchell works at the Massey Cancer Center, Medical College of Virginia of Virginia Commonwealth University.)
The main purpose of a patient’s chart is to provide a record of what has been done, what has gone on, and to help plan a realistic future.
A New Active Regimen in Androgen- Independent Prostate Cancer:
Doxorubicin (20 mg/m2 by continuous infusion for 24h) and ketoconazole (400 mg PO tid for 7d) in weeks 1, 3, and 5, and vinblastine (5 mg/m2 on day 1) and estramustine (140 mg PO tid for 7d) in weeks 2, 4, and 6, with weeks 7 and 8 off (hydrocortisone 25 mg PO qAM, 10 mg qPM was given daily to prevent ketoconazole-induced adrenal insufficiency) is a regimen that obtained PSA responses in 67% of patients with hormone-refractory prostate cancer. Twelve of 16 patients with measurable soft tissue disease responded. Median response duration was 8.4 months; median survival was 19 months. (Ellerhorst JA, et al. Clin Cancer Res 1997;3:2372-2376.)