Yeah I try, but sometimes I do just use the patients words because until Nancy has seen them, goodness knows what it really is. Nancy has a bunch of "when people say X,Y and Z I know exactly what they are talking about, they really have...." RLS is one of those kind of things. "You're going to think I'm nuts, but when I'm sitting on the couch at night...." Now with the recent ads on TV more folks who truely have it are coming forward. But I do put in what they report in the schedule line. Sometimes I might put in possible URI, UTI, Strep or what have you. But I feel it is NOT my place to change this self reporting, but to document what they told me. It is the clinical people, namely the doctor who takes the self reporting and her clinical observations and then she makes that diff. or difinitive Dx. That's certainly not my job, even if I do have an idea of what it might possibly be. That's practicing without a license. Just like the HMO's, right? Sorry I couldn't resist. Heck, even if you docs took the appointment yoursleves, it is still a Diff. Dx at best, right? Not until you have seen and probably laid hands on the patient should you be making a definite one, yes?
"It is inappropriate and dangerous to Dx and treat you over the phone. You need to come in." This is your call as the clinician, provider, doc, it is certainly not my place as the guy who answers the phones. Come on; your notes should obviously have a title that fits what you as the professional in the whole situation know or thinks that it is, not what the receptionist thinks it might be on first contact. This is almost silly. Soemtimes it is the most obvious things that we totally miss. This is one of those situations. No wonder you were the one that caught the URL, web address thing. You seem to have the "other" perspective for it.
You should certainly post this on the wish list to Jon and Vinny. Imagine someone reviewing your charts, even just another doc who needed notes or your patient moved, no less an audit of some sort (please no, keep the czar far away from us) "Puking with Dizzyness, Fever and Chills"... What a joke. This needs to be addressed.
