As a follow-up to this early post about doctor's handwriting, I would like to present an actual consult note from a patient's chart:
I don't know about you, but I can only make out maybe one word in that entire note. Can anyone tell me what it says? Or even what consult service wrote the note?
This is what I get from this:ReplyDelete
PT new, dictated
Hx ; ( and the rest is unclear) cermeroir
plan 1. renal
But the last part does not make any sense
I thought it said: Dx; cerumen. But I figured that couldn't be right.ReplyDelete
10/21/10, 1300. ENTReplyDelete
Patient seen, dictated.
Plan: 1. Stent
I loved our residents, because they usually still had good handwriting, and STAMPS! with their names on them. Then, after being doctors for years, their hands atrophy, and they write with their feet.
Ha, a cerumen stent?ReplyDelete
I was totally thinking of taking a picture from a chart today for the same exact reason. Seriously, if your note is intended to be read by others, how hard is it to try to be at least almost legible?
I agree with everybody else, but that last word is difficult to make out.ReplyDelete
My favorite is when the handwriting is like this, but it comes from a radiologist over the fax (and overly light and in shorthand!). Sometimes i wish there was a Rosetta Stone for these notations!
I've decided it's the following:ReplyDelete
1300 Pt Seen, Dictated
Plan 1.) renal,
(more not photographed?)
Clearly this patient has ear wax of nephrologic origin)
I mostly agree with everyone else but I think the last line isReplyDelete
Plan 1. Removal
That's actually better than one of the doctors I used to see at student health in college. His handwriting looked like he wrote with his feet while having a grand mal seizure...ReplyDelete
I think we've pieced together what it said (yes, I'm pretty sure the last word was "removal" since that seems like the only reasonable plan for cerumen). That was the whole note, excluding the signature.ReplyDelete
I wasn't being totally honest when I said I couldn't read any of it. I did eventually figure it out on my own, although to be fair, I did consult ENT for cerumen, so I had some big hints.
This proves why I'm a medical student - hieroglyphics have always been my interest. :PReplyDelete
I am a pharmacist, and I could read it! I guess I am used to it!ReplyDelete
I thin it says: ENT, Pt seen/dictated, Dx: cerumen, Plan: removalReplyDelete
I thought it said "Bx: cerumen" (as in biopsy was consistent with cerumen). the plan therefore made sense to me.ReplyDelete
Man, that "n" in "cerumen" kinda goes on forever! Maybe it was cerumen impaction (except all one word and with "impaction" abbreviated!) "Removal" really does look like "renal" . . . actually more like "renl" so maybe the doc was abbreviating again: "reml" for "removal" In any case, really, really bad and lazy!ReplyDelete
I also like how "ENT" looks more like "E _1"
So, can we show this note to people who oppose electronic medical records? :)
I'd say 8/10 nursing clinical conferences when my prof asks me what did the prog notes reveal.. I'm left to say I couldn't find a translator.ReplyDelete
When I'm asked what the consultant suggested in the chart, I generally respond that I still haven't gotten my Secret Decoder Ring for graduating medical school. It gets laughs and it gets the point across.ReplyDelete
i'm still having trouble getting past the fact that you consulted them for cerumen!!ReplyDelete
that note was incredible!!!
Pt seen. Dictated.
Dx: Cerumenimpaction (as one word)