Thanks. Yeah, it's funny how quickly I could dictate an H & P, especially the exam in my hospital days. But, I am going through something now, I have never gone through before. It is extremely difficult. And, documentation was an issue.
I used to do ROS with my nurse doing them. And, my nurse would do a good portion of the HPI. I guess it is similar to an ED note where there is a nursing triage note. But, the problem is there just has to be one word like RUQ pain in a three line nursing note that is not talked about in the room, and that is pounced all over. And, there is really nothing you can do. "Didn't you see this? What would you do normally had you known that?" You lose either way. You say, I do this or that. "Then, why didn't you do that?" Or I didn't read it. "And, it's why not? What it is there for?
I know what you mean by the template and editing things. But, you get in a hurry. Sure, you listen to the heart on the ear infection. And, maybe you hear a click or a murmur. And, then you order a cardiology consult. But, they don't correlate. Or you generally do what the template says you do, because you always do it. But, you didn't this time. So, now nothing is believable.
I definitely understand how you do it. That is how I did it. I certainly am not doing it that way anymore. David used to talk about this all the time. I don't know how many times I have left cough NO, and then diagnosed a pneumonia. It also depends what you call a good review of systems. Again, big difference between an admission H & P, a consult note, and a progress note. But, a ROS that states, "Denies nausea, vomiting, abdominal pain, diarrhea or bloody stools," is different than GI: NO.
I will say it takes longer to do than a template. But, if I type exactly what I did in the physical exam, it is correct. Even if I leave out abdominal exam when I did it, I am likely not going to type RRR, nl S1 and S2 with no murmurs, gallops or rubs (probably not that detailed) if it was abnormal.
The other thing that gets me in trouble is the following: You see a patient for an ingrown toenail. You deal with it. You sing off. Then the patient brings up a question of a referral. You agree. (Sure, I probably should have brought them back or done an addendum), but now there is an ENT referral with no documentation as to why. And, no matter how many times you tell your referral person not to send that note, they do 15% of the time.
Not arguing with you. Just getting advice. Or seeing how others do it. But, my nurse types in the chief complaint with just basic words, and changes the social history and reconciles the meds. I don't know how many times it says lives in Brewer with mom and dad, and now the patient lives in Hermon with just mom.
Again, the problem can be the mom states ten things to the nurse (which should be read) and then tells you the patient has constipation.
