Home Forums Discussions Feedback and Recommendations I think in problems not functions

when a patient comes in with a laundry list I try to steer them through things problem by problem. It would be handy to have the computer remember that I want a TSH when we are discussing thyroid replacement, and a HgbA1c when we are discussing DM, a CXR when they tell me they have hemoptysis, and a Creatinine when we are discussing renal insufficiency. As it is I have to have a list of my diagnoses before i go to the lab slip and then I have to remember what ALL the tests were that I was thinking about. It would be nice to check off the labs I want as I come up, then add on the diagnoses before I print/send and let the computer do the remembering for me. If I could remember everything I wouldn't need notes. (OK, so the notes aren't for me anyway - for insurance, lawyers, etc. etc.)

I do the same thing. I also try to get the whole list right away, just in case number 10 on their list is chest pain.

I use bullets with numbers in the HPI and make a list, usually getting the gist of it and moving on, in case some things overlap like shortness of breath and chest pain. As soon as I think of something I need to do, (TSH of CXR) I jot those down in plan, OR I write them on a piece of paper. Then when I am finishing the visit I read the whole plan and when I see CXR and one was not ordered, I remember to order it.

But I enter the room with a lap top and a sheet of paper, a face sheet from Amazing Charts. It has the name, DOB, insurance info and the photograph. I find it saves me a lot of time to have a place where I can scribble the note, CXR so I don't forget or so I can write down a second reading of the BP while I debate what to do about the different readings my MA and I got. I also jot down RBS or Pulse OX both so I don't forget the result before I write it in the chart and so I don't forget to include it on the BILL!

Thanks. So I am not alone. I'll just use that handy old tool - paper.