Exactly! How did we miss that. That has to be close to numero uno on the things to fix. All of ours comes from our MAs, but even if I see a patient on my own, the chief complaint is supposed to be in the patient's words. So, if a patient says, "doc, been pukin' all day," that is the chief complaint in the patient's words. We are not supposed to edit that to Vomiting last 12 hours.
It's what's written in the chief complaint that populates the subject line of the visit history. Do we really want, "Every time I get up to go to the bathroom, I get dizzy," for the subject line. No, we want orthostatic hypotension there which would be the diagnosis. Maybe that should not be part of the note, but editable. I always have trouble with this. Say a patient has dysuria. You send them for a U/A and culture and the diagnosis is Dysuria. You don't know that it's a UTI yet. So, if we used the diagnosis as the subject line (which would be much better), then dysuria would be there. But, if the culture were positive, then I would argue for adding a slash like Dysuria/UTI.
That's the first thing I look at when trying to go back to review a patient's chart. If a five year old has three UTIs jump out at me, I know to make sure that at least an U/S has been done and maybe a VCUG.
Thanks Paul.
