Steven, I did a rotation w/ an old school family doc when I was in school. He was a D.O. that was in practice 35 years.
This is an excerpt from a chart, very similar to yours. However he actually used the SOAP format which I though was cool.
S: fever
O: tonsillar exudate
A: tonsillitis
P: penicillin
There was a D.O. in my town of Brewer, ME who died years ago (Arthur Dearborn, D.O.) but I take care of his family. His son is in his 70's and I care for the son's family/children/grandchildren/great-grand's. It's really quite cool. They toured me through the old family homestead, where Dr. Dearborn practiced. They gave me a few of the antique medical tools. They wanted me to have it all, but I couldn't in good faith accept such a generous gift. Rather I took a few basins and a couple of surgical instruments that we use everyday in our office. He graduated from the original D.O. school in Kirksville, MO in 1932.
I looked a some of Doc's notes. These were truly classic. 3x5 index cards kept in cardboard boxes. He had stacks and stacks of these boxes. On the card read:
Jane Doe
3/2/77
pneumonia
balance $15, paid.
He devoted more letter/characters to the billing than to the office note!
He knows what he did, and his record was just enough to remind him what he did. Which is the purpose of office notes in the first place. He clearly would have prescribed antibiotics in those days, probably a shot of penicillin. He didn't have an insurance company asking for his notes to prove what he did. And he had FAR FEWER lawyers knocking on his door than ours today, touting this line of B.S. "If you didn't write it down, you didn't do it."
If Obama truly wants healthcare reform, we need to go back to the way it was done back in the old days. Keep it simple and keep it real.
