Aug 4, 2026
Written By Elizabeth Cifers
If I had a dollar for every retina note that said “stable, monitor,” I could probably fund my caffeine habit for the rest of the year.
The problem is not that patients are stable. We should all be thrilled when patients are stable. The problem is that stability is a conclusion, not an explanation. And when the assessment and plan stop at the conclusion, the clinical story quietly disappears.
Retina specialists make complicated decisions all day long. They decide whether to continue treatment, extend intervals, shorten intervals, observe, operate, switch medications, repeat testing, or simply leave well enough alone. Those decisions are the practice of medicine.
Yet somehow, many notes reduce all of that thinking into two words.
Stable and Monitor.
From a clinical perspective, the physician may know exactly why the patient is stable. The problem is that nobody else does.
The next person reading the chart may not understand why treatment was continued instead of changed. The auditor reviewing the record may not understand why the visit occurred at all. The payer certainly cannot see the decision-making process that happened inside the physician's head.
And unfortunately, medical records are graded on what they say, not on what the physician was thinking at the time.
Consider a patient with wet age-related macular degeneration receiving ongoing anti-VEGF therapy. A plan that states "stable, continue injections" leaves out the most important part of the encounter. Stable compared to when? Stable despite persistent fluid? Stable after recent improvement? Stable enough to extend? Stable enough to maintain the current interval?
Those distinctions matter because they explain the reasoning behind the treatment decision.
The same issue appears with diabetic retinopathy, retinal vein occlusions, epiretinal membranes, and countless other conditions. "Monitor" tells the reader what will happen next. It does not explain the why.
The irony is that many physicians are already making excellent decisions. The documentation fails to capture them.
A defensible assessment and plan does not require a novel. It simply requires enough information to connect the findings to the decision.
Now the reader understands not only what happened, but why.
That distinction becomes increasingly important as audits become more sophisticated. Reviewers are no longer looking only for signatures, diagnosis codes, and completed procedure notes. They are evaluating whether the record supports the medical necessity of the decisions being made.
And that support often lives in the assessment and plan.
The goal is not to document more. The goal is to document the thinking that already occurred.
Because "stable" and “monitor” are rarely the whole story.
And if the entire story fits into one word, you are probably leaving the most defensible part of the encounter out of the record.
If your assessment and plan reads "stable, monitor," there's a good chance the physician's clinical thinking never made it into the record.
That's fixable.
Whether you need a documentation review, a coding audit, a workflow assessment, or a broader look at how your practice operates, I'd be happy to help.
Schedule a free consultation, and let's talk about what's really happening in your practice.
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