Robert Oubre, MD | The Doctor of Documentation
@Dr_Oubre
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I simplify clinical documentation & billing | Have helped 580+ become efficient & effective clinicians by optimizing notes through my video courses!
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In 8 years I’ve written and read >20,000 SOAP notes.
Most could be improved.
3 tips to writing better notes:
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• United Health will PROFIT about $22.3 billion this year.
• 50% of hospitals will lose money this year.
• 47% of US healthcare workers plan to leave within the next 3 years.
That is the current state of US healthcare, and it should terrify everyone.
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Twitter is free education for those in medicine...
but you have to follow the right people.
Here are my 9 recommendations.
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What should you call that elevated troponin?
This is NOT taught well and impacts more than you think.
Understand it in 2 minutes:
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Be the doctor nurses want when their family is admitted.
Nurses know.
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Pro tip: Don't ever assume the role of a person in a patient's room.
I've asked "Is this your daughter?"
...it was his son.
I've asked "is this your wife?"
...it was his daughter.
It can get awkward.
Now I say, "And you are his...?"
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Don’t do it.
Don't lower your standards because of other’s behavior.
Some days you may not live up to your own standards. That's okay. Forgive yourself and do better tomorrow.
But a career in medicine can be brutal, and one brutal truth is this:
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The pendulum has swung too far.
Penalizing falls in the hospital has resulted in patients who aren’t allowed to get out of bed.
They get weaker, depressed, constipated, pressure ulcers and ultimately need SNF placement.
Ambulation should be viewed as a key to healing.
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The pendulum has swung too far.
Penalizing falls in the hospital has resulted in patients who aren’t allowed to get out of bed.
They get weaker, depressed, constipated, pressure ulcers and ultimately need SNF placement.
Ambulation should be viewed as a key to healing.
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An identity outside of medicine gives you freedom within medicine.
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We had a hospitalist who always had the lowest length of stay. We asked him how he did it:
"Every day, I ask every patient 'what do I need to do to get you home?'"
It seems harsh at first but could be a good way to address barriers and keep that conversation going.
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Here in America, we wake patients up to ask about their pain level.
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In July 2014, I quit intern year.
1 conversation convinced me to return the next day.
5 pieces of advice every new intern needs to hear...
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Be comfortable saying "I don't know" to patients.
Being honest about what you DON’T know reassures them you are confident about what you DO know.
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“If it’s not documented, it didn’t happen”
But now with templates and auto population
“It’s documented, but did it really happen?”
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If a nurse asks you to see a patient, do it.
Experienced nurses' instincts are invaluable.
And if it's an overcall by a young nurse, your immediate response will have established trust...and you can provide education.
And remember...
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Being a senior resident is stressful...
but are you over-complicating it?
8 Tips for being a great senior resident
(That don’t require knowing everything)
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I met a physician who has a life-time state-wide non-compete.
That is one of the most absurd things I've ever heard.
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My wife has had 3 doctors in a row walk in and not introduce themselves.
Are we that lost in medicine?
I understand being busy, I'm a hospitalist, but I still have 5 seconds to introduce myself / confirm the patient's name.
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Imagine a loved one being treated incorrectly for their MI.
Yet...do YOU even understand when an NSTEMI is really an NSTEMI?
Finally understand it in 2 minutes:
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Delivering bad news isn’t easy.
Unfortunately, this isn’t taught well.
6 tips to make this easier for you and the patient:
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CKD is defined as reduced GFR for >3 months.
But in the hospital, you don't have 3 months. You might have 3 days.
Yet you're asked to make a diagnosis.
Here's how:
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Residents are telling me they're still being taught old billing rules.
Reminder, since Jan 1, 2023:
🔶 HPI has no strict billing requirements. It simply needs to exist
🔶 Same for physical exam
🔶 ROS is no longer required
🔶 PMH, FH, SH are no longer required
Also a reminder:
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Every hospital in America needs a click reduction committee.
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What should you call that elevated Creatinine?
That's the easy question.
But what is their baseline?! That's tougher.
A thread 🧵
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Hospitalists who start rounding at 6 AM and are done by 7:30,
I know the game you’re playing and it’s horrible patient care.
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Many have the same jokes they tell patients over and over.
What’s yours?
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What should you call heart failure?
Systolic & Diastolic?
HFrEF & HFpEF?
The answer might surprise you.
A thread 🧵
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As a med student, I was overwhelmed with history taking.
How could I keep come up with pertinent questions for differentials WHILE interviewing the patient?!
2 tips I use to stay organized:
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In July 2014, I quit intern year.
1 conversation convinced me to return the next day.
5 pieces of advice every new intern needs to hear...
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How to gain the trust of nurses:
1. Know their names
2. See a patient when they ask you to.
3. Don't get defensive when they question your plan.
Nurses, what tips would you give???
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The 3 midnight rule is back.
You may be 3 years into your career without knowing this rule bc it was put on hold for covid.
Here's what it means:
Your patient must stay 3 consecutive midnights of INPATIENT care in an acute hospital setting for Medicare to cover SNF services
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Med schools should not only teach history taking, but also patient redirection.
It's tough, and nuanced...
but "never interrupt a patient" is not the right approach (I'm sure many will be triggered by that statement).
But being a good doctor does not mean...
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Over the past 8 years, I’ve admitted >5,000 patients.
I use the same strategy every time to:
• Stay organized
• Be Efficient
• Be complete
Admissions can be overwhelming.
Stop stressing, steal my 4 tips below ⤵️
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"CHF" doesn't cut it anymore.
You have to classify heart failure to truly know how to treat the patient.
3 tips to classifying heart failure and ensuring proper care:
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A note to new residency grads:
You can’t know everything.
I sit in an office with 8 other attendings & we ask each other’s advice & opinions.
Even the 15-year seasoned attendings.
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I say this as a hospitalist:
We need to prioritize primary care in this country.
Traditional primary care is becoming rare. Ex-conventional docs tell me they're selling supplements, etc bc it actually makes money. Insurance reimbursement is just too low.
Thoughts PCPs?
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Should you call it sepsis?
TWO definitions. ONE big problem.
Understand the problem and a solution in 1.5 minutes.
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I asked, “What do you like to see on discharge summaries?”
I received 100+ responses.
6 tips on writing the ideal discharge summary (and improving patient care):
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One of my favorite intern comments:
Intern: "Hey they told me Ms. X is on the floor, so I ordered a CT head."
Me: "...I think they meant she's arrived..."
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I developed anaphylaxis to an allergy shot yesterday morning. An NP and a few nurses saved my life.
They did a great job of identifying early symptoms and did not delay in giving me Epi. Took care of my kid during the episode too.
Remember, anaphylaxis ➡️ Epi 1st. Not steroids.
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It was 8 PM. Late.
My attending called me.
"Hey, Robert. I was writing my note and realized something..."
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My patients are not my top priority and I'm a damn good doctor.
This is an uncomfortable truth, and more doctors should admit it.
Putting your patients before your own health is the quickest way to burnout and illness.
Take a break. Set boundaries. Care for yourself.
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Got off a peer-to-peer call with a physician who proudly stated he doesn't see patients anymore because "this is all I do."
I looked him up.
1 year of clinical experience after residency.
Then >10 years of appeals and insurance work.
Pathetic.
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How most HPI's are written:
Details of a chief complaint. That's it.
5 tips to using the HPI to make you a better doctor.
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8 ways to improve your documented physical exam:
1. Stop using templates
2. Stop using templates
3. Stop using templates
4. Stop using templates
5. Stop using templates
6. Stop using templates
7. Stop using templates
8. Free text only what you did / saw
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Hospitals get paid the same amount no matter how long a patient stays.
So this misconception that hospitals keep patients in the hospital to make more money is incorrect.
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Med schools should not only teach history taking, but also patient redirection.
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270,000 Americans die of sepsis each year.
But we can't agree on how to diagnose it.
The problem is more complex than you think...
A thread 🧵
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You will do better than most of your peers if you
1. Care
2. Are organized.
Intelligence only goes so far if you don’t have those.
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You're not paid extra to be a compassionate bedside doctor.
What motivates you to do so?
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You are not recognized nor rewarded, especially financially, for good, compassionate patient care.
Its SO easy to recognize this fact and lower your standards because "no one is watching" and “no one seems to care."
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We waited 6 days for insurance approval of home IV antibiotics.
Which we completed inpatient while waiting.
🤦♂️
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My epic secure chat struggle:
I want to say thank you.
But don’t want to get a message back “you’re welcome.”
Am I alone in this?
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Clarity in notes 101::
“History of" = No longer present (in coding language). Ex: “history of diabetes.” Is their diabetes really no longer present?
“With” = Still active. “Patient with diabetes” is better.
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I want to make something clear.
Sick patients alone do not cause burnout.
It's the mental stress of the bureaucracy waiting for us on the computer that does.
My most rewarding days are when I have unstable patients and I know I did good work.
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It's the ACT of documenting that forces you to think through a patient's case.
Rush it and you're rushing through an important tool for clinical reasoning.
Medicine is fast but at times we must think slow...
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I received a patient who had FIFTEEN chronic medical conditions listed in their HPI.
But no mention of their lung cancer...
For a patient who presented with shortness of breath and pleural effusions.
I know I'm a broken record: 3 - 4 pertinent medical conditions in your HPI!
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Advice
#1
: Make it to month two.
The learning curve is STEEP and it will never be as bad as it is now.
You are drowning in mental exhaustion and as you learn, each day will be easier than the one before.
Each month will be better than the last.
Make it to month two.
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How to write better discharge summaries:
1. Tell a narrative story (this is obvious, but not the norm)
2. Write on day of discharge when it's fresh.
3. BOLD pending at discharge labs or things that need to be done as outpatient.
PCP's, any other tips?
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This also means you need to get a better history.
Gather events leading up to when a patient started feeling abnormal all the way to presentation to the ER.
The patient wont tell it that way. It is your job to organize the story.
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One of the best things you can do for patient safety:
Be approachable so nurses feel comfortable asking questions and expressing concerns.
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He said the quiet part out loud during a peer to peer:
“As a cardiologist I agree with you…but my protocol says I have to deny this.”
Then WHAT is the point of peer to peers?!
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In Summary:
1. Make it to month two.
2. Don't compare yourself to others
3. Take control
4. Seek feedback.
5. The isolation won't last.
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So, find your own motivations for providing good, compassionate, bedside care.
Find internal ways to congratulate yourself and thrive off small moments of gratitude.
Find a job that supports your standards.
Share your standards with others and when necessary, use words.
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Most people are still using CAP and HCAP for pneumonias.
You should stop.
Here’s why:
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In 10 years I’ve written and read >30,000 SOAP notes.
Most could be improved.
3 tips to writing better notes:
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This is burnout. But not the “I’m leaving medicine” burnout.
Something worse.
Something produced by a system that promotes volume, not value. Something produced by a system perfectly designed to get a product: A machine.
A disconnected machine.
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Did you treat their hyperkalemia but forgot they're on spironolactone and lisinopril?
If those meds are listed under their appropriate sections, you'll remember then.
Good care is thorough.
A good note is thorough.
Good notes are good care.
For both you and patients.
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Then little by little, you become cynical.
The bare minimum becomes standard.
Patients become a box to check.
Patients become an annoyance.
Patients become… money.
It becomes a job.
A job you’re stuck in.
A job to sustain a life style.
A job… you did not foresee.
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If someone is asking for your help…they want your help.
It’s not the time to decide whether they SHOULD be asking for your help - Do this on the back end in the form of respectful feedback.
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My Intern motto to you:
Endure the suck.
Embrace the learning.
Thrive in the friendships!
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But you’re not a machine. Neither are your patients.
You must strive to maintain the human connection not because of the system, but despite it.
You must set YOUR standards and make the system work within them.
You may not think this applies to you but...
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When you’re taking a history, ask about the day BEFORE they started feeling bad.
This can often reveal important details.
“Okay, so Saturday morning you woke up short of breath… so Friday you were completely normal?”
“Well, not really…”
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Advice
#2
: Don't compare yourselves to others.
Those who seem to have it all together don't.
How do I know?
Bc they'd come to confide in me later that they were struggling.
And the shocker?
They thought I was one of those people!
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Include pertinent positives or negatives after introducing new information to help the reader determine a diagnosis.
Do NOT just list them off at the end (my pet peeve).
Ex: “She’s had 1 week of dark, tarry stools. She does not drink alcohol. She takes 8 Advils a day.”
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It’s good to be alive today.
The impending sense of doom while wheezing for the first time in your life and watching your BP drop as you slowly lose consciousness is not fun.
Oh and Epi pens should be free, widely available and should come with AEDs in public places.
🙏
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Is this an unpopular opinion?
I hate continuous IVF.
I do not order them.
If I do, I use a stop time.
What say you?
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Do you feel overwhelmed by cross coverage at night?
You need a framework to stay organized.
Here are 5 tips to thrive in these high stress situations:
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Wow. What a wild ~24 hours. I never imagined doubling my followers by promoting others.
Welcome everyone. I’m a hospitalist and CDI medical director. I post tips on documentation, bedside manor, communication, efficiency, and career / self development. Prepare for CDI 😂!
Twitter is free education for those in medicine...
but you have to follow the right people.
Here are my 9 recommendations.
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Med students, everything you learn does matter.
You don't have to remember it all, but remember it exists.
Ex: After seeing a patient, I had a suspicion she had 21-hydroxylase deficiency.
I remembered LITTLE about it.
But I knew to look...
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Insurances are REJECTING your diagnoses.
Especially "respiratory failure."
Bullet proof your diagnosis:
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** A note to students: this will show your upper level / attending that you are thinking about appropriate differentials in your note & as you present. **
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@DxRxEdu
Co-founder of Clinical Problem Solvers Podcast.
A brilliant teacher of clinical reasoning.
His latest 1 - 2 minute teaching service videos are 🔥🔥🔥
Teaching service Day 2/14
Our patient was urinating 8L of fluid a day. This prompted me to read about polyuria.
Almost only 2 min!!!
Please share your thoughts
❤️
@rabihmgeha
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How to avoid queries 101:
“History of" = No longer present. Ex: “history of diabetes.” Is their diabetes really no longer present?
“With” = Still active. “Patient with diabetes” is better.
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Doctors avoid calling patients / family bc they fear a long conversation.
Hack: Set time expectations.
“Mr. Joe, the hospital is busy but I wanted to take the next 5 minutes to discuss your wife’s care.”
We become frustrated when someone doesn’t meet our expectations,
But...
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There is NO billing requirement for raw lab data to be pulled into your note (For an inpatient H&P, consult or follow up charge)
“I reviewed the labs” is enough.
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If you wanted to tweet the same thing everyday for a month to drive home an education point from your specialty, what would it be?
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Diagnosing a heart attack should be simple - not complex.
But most physicians mix up the three I's:
- Ischemia
- Injury
- Infarct
Here's how to simplify it:
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Avoid "yesterday" and "today" in your notes but especially in your discharge summary in the middle of the hospital course!
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Advice
#5
: The isolation won't last.
New city. New people. New job.
You feel alone.
But you and your co-residents are forging the strongest, richest relationships through a shared struggle.
Within the next few years, you'll cry with the people you see around you now.
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@DxRxEdu
@AaronGoodman33
Posts daily board-type questions from step 1 to hematology boards.
But good for any stage of training.
I don't know how he keeps up with his consistency!
Cefepime = ceftriaxone + pseudomonas coverage
Zosyn (pip/tazo) = cefepime + anaerobic coverage
Meropenem = Zosyn + ESBL coverage
Ertapenem = Meropenem - pseudomonas coverage
Thank you for coming to my TED talk.
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if you’re still reading you know the truth in this. Burnout exists and YOU are susceptible to it.
It’s not an explosion.
It’s a slow rise to boil that’s easy to miss.
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letting your patients go on about unrelated tangents.
Irrelevant time is time not spent on
🔷 investigating into their symptoms and history
🔷 exploring differentials
🔷 educating them
You do not have unlimited time.
You also have other patients whose time you must respect.
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