Finally, at least for now, and I have other questions on workflow documentation as well. As I have recently learned, no matter what you document, there are certain people out there that can spin the hell out of anything.
But, here I have questions on ROS. Again, template ROS with 10 words there to that default to no, and then are changed to know, again show that templating was used and too often the patient has severe pneumonia and Resp reveals normal.
But, I have seen a trend that is going on especially in the ED, where after a fairly detailed HPI, the ROS will say a 10-point ROS was taken and was all negative except for those mentioned in the HPI.
And, some will have GI documented as Denies and then lists ten things such as denies nausea, vomiting, blood in stools, abdominal pain, constipation, diarrhea, etc. Then c/o vomiting is changed and is in bold. This makes it appear as though all of the things in the GI ROS was asked but when there are ten or twelve of these that are detailed like this, there is no way the provider went through all those. It just seems like, once again, a "detailed" template was used where maybe diarrhea was the actual chief complaint. Thoughts here would be helpful.
I just want to comment (and this is in no way a good or bad thing about specialists), but I recall when I did H & Ps in residency or as an attending or ER notes, I spent a good deal of time going through the ROS. A consultant has a little more time and is also expected to provide a thorough and accurate note and so does not have a template that lists six abbreviations with Cough, Fever, Diarrhea, etc. But, it would be hard to go through a thorough list with OM.
