Yeah, and I've seen stuff at VA's where as best you can tell no one has actually examined the patient in 20 years, and the exam just gets re-copied.
I was recently at the VA and saw a physical exam in the computer that described my white female patient as a "pleasant Samoan gentleman." Not sure how that came about.
I like listening to the hospitalists dictate the physical exam. They can do a head to toe in about 6 seconds. Although I will say they are the only docs (other than pulmonary) that I have seen lay a stethoscope on the pt!
that is so true! oh my goodness! I had a patient who was NPO from a stroke, totally incapable of swalling. Primary doc's note "patient eating and drinking well."
You forgot the part when the cards consult comes by and documents some 1/6 murmur or thrill or whatever, and how every single person after that will document the same thing whether they hear it or not.
If this is not the truest cartoon ever!!!!! I mean, like, EVER.
I've actually had to write: "In contrast to every other physical exam that has been copied forward to this point, the patient does not have equal pulses bilaterally as he is a unilateral amputee."
This looks absurd for me. Colombia (where I'm from) is a third world country and here we need to rule out mentally everything before ordering any test. In Medschool we do have a whole semester of physical examination and clinical history...in the beginning you take like 3 hours doing a complete interview and examination but after almost a year of pimping (once they asked me the weight of a lymphocyte) from your teachers and hundreds of patients you take like 20 minutes. If a patient is admitted you examine him/she and write your impressions (they are called evolution here) in the chart. You will be as good as dead if among your initial differentials the discharge diagnostic is missing.
PERFECT!! Why don't they just teach us this method from the beginning?
Very true - but if I forget something, I just document what I can observe - like no JVD, normal appearance, no respiratory distress, vitals reviewed, etc.
Very true. I was with my attending once when he started to form an assessment and plan from a patient's vitals that were displayed on the computer screen. Then I pointed out that the patient's listed fever was from 5 months previous.
Hi "ZZZ",usually I read your blog. Followme in http://humor-medico.blogspot.com
We have a doc who formats their note while talking to the nurse. You give this doc a verbal report on the pt, and there they are, typing away. Ummnn, I am good, but dang, I can be wrong.For awhile I stopped giving verbal report to this doc; unfortunately there is the copy/paste function.
I like "CN 1-12 normal". How often do they really examine the olfactory?
If they really make an effort they ask the nurse for an assessment and then say hi to the patient before dictating their note. Critical care time: 45 minutes!