Why medical notes have become billing scripts instead of patient stories

We tell ourselves documentation is for patient safety. For continuity. For protection. But let’s be honest. It’s for billing. And once you see that clearly, it is hard to unsee.

In training, I was taught that the note reflects the thinking of the physician. That it should tell the story of the patient and the rationale for each decision. But in practice, it does not. It is a tool for revenue capture.

More specifically: The longer and more complex the note appears, the more it justifies the code. So we inflate. We paste. We “smart phrase” our way through nuance. And over time, we lose track of what we were even trying to say.

I have seen brilliant residents spending more time optimizing templates than reviewing patient history. I have watched attendings rush discussions because “I already have a dot phrase that covers that.” I have seen patients sit in silence while their physicians tried to reverse engineer which template would unlock a Level 4.

This is not care. It is simulation. A performance optimized for compliance, not healing.

We say the note is for memory. But that is a lie too.

Patients rarely read the notes. Colleagues rarely trust them. Billing staff use them as a defense. The EMR becomes a game of plausible deniability: “If it is not in the note, it didn’t happen. If it is in the note, I am covered.”

But how many of us have looked back at our own notes and had no idea what we meant? How many times have we reread our documentation and realized the real decision-making never made it in?

Documentation, in its current form, is not memory. It is bureaucracy disguised as safety.

So what do we do?

Some try to write “better notes.” Others try AI scribes, or hire scribes, or use templates layered on templates. Some of us just give up and paste whatever satisfies the system.

But the larger truth is this: We do not need better notes. We need a better system of memory. One that honors the clinical story, protects the patient, and respects the time and cognition of the physician.

I am still working through how much this broke me. The late nights. The hidden stress. The constant tension between telling the truth and getting the code. But I have come to believe that healing the system starts with reclaiming the narrative.

The note should not be a weapon. It should be a shared artifact of care. And maybe, someday, it will be again.