I just sit here waiting for your posts, lol. I couldn't agree with you more. I email those to staff and make fun of those notes. They are a joke. They are simply for protecting their [censored] and coding. I think it actually makes things worse. They enter the meds like four times. Came in with this, we really thought he should have had this, we added this, he left with this. Supposedly, they ask two year olds have they been sexually molested or physically abused and do they drink alcohol, etc.
Now, they include the labs in them, which seems as though it would make sense, but then they are in a column with the ranges, etc. Takes up another 2 1/2 pages.
I always feel bad about templates, but they always write we did a 10 point ROS, all of which were comparable to Lebron James except for the cough he complained of when he came in. See page 4.
My favorite part is where they are forced to say what they considered. Now, it seems like a good idea, to show you thought about Lyme disease, etc. But, then you don't test for it. Many say meningitis. Well, you let them leave and you didn't do a spinal tap. Seems perfect for the lawyers.
Now, we have something I have never seen. It is so strange. And, it has been in the last three ED reports of the patient. And, since she has had multiple seizures, she has had four or five. But, in one of them, before the after the HPI, which is after five sets of VS, part of her neurologist's consult note was inserted. But, and I am not exaggerating, since it was at least 1/2 of her note and contained ROS and meds, etc., you literally couldn't tell where the note stopped and the ED report commenced again. This happens in three separate ED notes. And, the consult was in different places in each.
Most of these ED visits could be:
Presents with cough
Exam revealed wheezes, all other normal.
Impression: Asthmaatic bronchitis
Plan: Proair MDI 2 puffs qid prn cough.
F/U with PCP, return if worsening.
Now,that is a bit too short, but man. Medicolegal stuff is crazy. I will give the template credit that it is hard for them to miss something. But, then they treat GAS pharyngitis with Bactrim.
