Documentation by Exception is the Dredge of EHR Documentation

There was a very bad practice that was started thanks in large part to EHR software implementations. That practice is called documentation by exception and it’s employed by many (most?) EHR vendors. For those not familiar with documentation by exception, here’s a definition:

Charting by exception (CBE) is a shorthand method of documenting normal findings, based on clearly defined normals, standards of practice, and predetermined criteria for assessments and interventions. Significant findings or exceptions to the predefined norms are documented in detail.

In the US, we all know why this type of documentation was implemented. By documenting all of the normal finding along with the exceptions, then the doctor is able to bill the insurance company at a higher level. I totally understand why doctors want to bill at a higher level. In fact, it was the argument that most EHR vendors would make when they were selling their product to doctors. The EHR was able to help doctors bill at a higher level and get paid more.

While this is going to be hard to change for this reason, there are so many unintended consequences associated with using documentation by exception in these practices. I know so many doctors that are literally embarrassed to share their chart notes with their colleagues because their chart notes are these long, cumbersome notes that are filled with normal findings that provide no value to anyone. Many of these doctors have resorted to creating a separate “short” note that only has the relevant “exceptions” detailed when they send their chart notes to another doctor.

Every doctor knows what I’m talking about, because they’ve found these long lengthy notes that are totally unusable. Plus, in many ways it puts a doctor at some risk if they documented a long list of “normal” items when in fact they didn’t actually check to see if everything was normal or not. However, more important than this is that the doctor can’t even read their own historical notes because they’re so cluttered with all these “normal” findings that it takes real work and effort (Translation: Wasted physician time) trying to search through these awful notes.

If somehow all of these normal findings that were being documented could add some value down the road, then I might change my mind about documentation by exception. However, I can’t imagine any useful clinical benefit to documenting a bunch of normal findings that weren’t actually checked or that were only casually observed. If you didn’t document something was wrong, then we can assume that everything else was normal or at least the patient didn’t complain of anything else. Why do we need to document it clinically? The answer is we don’t and we shouldn’t (except for the getting paid comments above).

We need to find a way to abolish these documentation by exception notes from healthcare. In the US this will be hard since it’s so tied to the payment system, but I’m sure smart minds can figure out a way to fix it. Every doctors I’ve ever talked to wants this solved. It almost makes the EHR notes useless to document this way. This is one more driver in the US system towards concierge and direct primary care models. In these cases, the doctors aren’t worried about reimbursement and so I can’t imaging they’d even consider documenting a patient visit in such an awful manner.

A part of me wonders if EHR vendors will work to solve this problem as well. They could have the beautiful note and the crappy, mess of a note. They’ll use less vulgar terms like the “clinical note” and the “billing note” or something like that, but maybe that’s a small step in the right direction to satisfying the clinical needs (short, concise, relevant notes) together with meeting the billing requirements note. It’s sad that EHR vendors need to do something like this, but it would be better than the current state of EHR notes.

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John Lynn

John Lynn




  • There is an easy solution to this problem. There is only one charge/payment for any type of office or in hospital visit regardless of the circumstance. It makes no difference what was documented. Fix this charge at about the 99213 level of reimbursement. Then only the important info will get documented especially info needed to defend a future law suit and or to tell the story of what is going on with the patient at that particular visit so as to make an intelligent referral if needed.

  • SGCMD,
    You’d think that would work, but then you have to imagine what the worst person’s going to do. They’re going to make sure that every visit is as simple as possible since they know they’re going to get paid the same amount either way. So, they’ll require you to come back for a new visit for each thing you want treated. So, we’ll pay 3 times (at a higher rate) for what we could have paid for just one visit. Sad, but true.

  • I know for a fact that Cleveland Clinic outpatient internal medicine will only address 2 of your problems at a clinic visit. If you have more than two problems, another appointment needs to be made.

    The other option is billing for time spent on a patient’s problems either face to face or filling ouit forms etc, like attorneys or accountants.

    All methods of charging professional services are ripe for potential abuse.

  • […] I was recently talking to someone about why EHR documentation is so awful to read. It’s because billing requires that the doctor spew out all this useless documentation in order to justify billing at a higher level (Side Note: Be sure to check out my previous post about Documentation by Exception Being the Dredge of EHR Documentation). […]

  • I respectfully disagree with your assessment of Charting by Exception. I believe it is just the opposite. CBE is documenting only abnormal after defining ‘normal’. Typically, all normals are not documented at all in the record. At least that is the way I understand it.

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