Medical Reports – Why I hate writing them
Of all the work I do, what I despise the most is “Writing Medical Reports ”. In the book entitled “ Eat that frog” , Brian Tracy wrote that you should do the work you least like, first thing in the morning. Since writing medical reports is the job I hate the most, I try to follow his advice and finish my reports early in the morning, at least once a week.
Why do I hate this part of my job?
The first reason is because I find this task to be boring and uninspiring. It’s not what I am trained for. It requires me to rummage through years of a patient’s records to get a cohesive account of her condition and then, write it down on paper.
Types of medical reports
There are 2 types of medical reports: the first is a specialist report where you can write in free flow what you want on a piece of paper. The other one is a questionnaire. I really hate the questionnaires. There are several reasons for this. Firstly, someof the generic questions that are asked are very illogical that I find it difficult to answer them. Secondly, the amount of space given to answer questions can be very limited. One can always attach another paper to elaborate, but who wants to do that?? I am always not in the mood to give more information than the space given to me even if it necessary. One has to really go through the notes which are often not properly filed, to get the information required to fill up the forms. Then comes the dreaded question: “Is there any other information you would like to give?” Once I left the space blank and an insurance agent complained to the Malaysian Medical Council (MMC) asking why I left this column blank. I was asked by the MMC’s ethical committee to reply to this question. I told them that I had given all the necessary information in the questionnaire and I did not have anything more to add, so I left it blank. He withdrew that complaint. Nowadays, I just write a few words in that space even if the information has already been given in the questionnaire– just to satisfy the insurance company.
The second reason why I hate to write medical reports is because the remuneration for the time spent is meager. One can spend a great deal of time on one report and get paid a small, fixed amount, which has been predetermined by the hospital and the insurance agent. Some reports take only a few minutes to write, especially if the patient has only seen me once before but others may have been in my care for 20 over years and I have to decide which part of their medical history is relevant to be included in the medical report. Writing such reports can take up to at least an hour. The fee is the same. This is unjust. To add to this many private hospitals take a portion of the doctors’ fees for writing these reports as administration fees.
The third reason why I hate to write medical reports is the fear that I will write something wrongly and that it will affect the claims of a patient who may be rejected coverage by the insurance company. Although it is not my job to help a patient, I have had the experience of patients coming up to me in anger because their claims or insurance applications had been rejected because of my reports. Therefore, my reports have to be accurate so that the correct information is given to the insurance company in order not to antagonise my patient. This can be tricky and is often the reason why I am so stressed when writing medical reports.
My table usually gets cluttered with patients’ files and notes and my clinic nurses will constantly be reminding me to write these reports because they, in turn, are under pressure from insurance agents who keep calling them for the reports. Insurance agents usually request for medical reports to be written quickly so that they can submit these and get paid for selling an insurance policy. My delay in writing a report delays them from getting paid.
So you see, why I “Eat the frog” one morning every week because this is the one job that I hate.
How to make writing a report easier?
Having an organised system for medical record helps. My hospital started in 1994 before the era of medical digitalization. We have physical records. We are slowly moving to digitalization but the senior doctors in the hospital are still happy with physical notes. I moved to digitization in 2000 when I started my own clinic in the hospital. All my out patient records are typed into a software in my clinic so I can retrieve them easily. So writing a medical report while looking at my outpatient record is easy. However, inpatient records are still in the physical format so I still have to go through th e physical files to get all the information required.
So what advise can I give doctors going into private practice?
- One day when you become busier you will be asked to write medical reports. So be prepared. One advice is to digitalize, at least, your clinic records. If your hospital is already digitized, then have a look at how the data is kept so that you are able to retrieve all the data easily to write your report.
- Type out your report. Do not write it down. There are many advantages to typing out a report. First, your medical records department will be happy to just click and paste the report and send it to the insurance company. Second, the medical records department need not worry about getting back to you to decipher your illegible handwriting. It saves everyone a lot of time. Third, you can keep a copy of the report.
- Keep a copy of all reports that you write. One day, the same patient may come back to you asking for another report and this is when you can smile and just copy or update the old report and get paid for a quick job done.
- Spend time studying the patient’s history thoroughly before starting to write the report. A wrongly written report may affect the patient’s claim to be insured. She will not be happy with you. However, never try to change the report to please your patient. This may later come back to haunt you.
- Set aside time to write these reports every week. Some insurance agents’ livelihoods may depend on your medical reports. The earlier you can write them the earlier they can get paid. Being busy, I am guilty of not doing this as promptly as I should too.
- Try softwares that writes reports as you dictate and that can be more time efficient
3/3/2022 ( 62 years old)
I would like to thank
My wife Sarojini for editing this article
Dr Gunasegaran for reading through this article and giving good suggestions