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Hx: runny nose × 3 d—fever 101 ax yest afternoon—very fussy last night'some cough—no Breakfast—no V or D
PE: Well—N.A.D. sl fussy—orients to Mom—Chest clear—Rt TM honey colored opaque bulging—Lt creamy fluid level 2/3 immobile
Dx: B.O.M.
Plan: Amox 250 tid × 10 d/Ret 3 wks
Does this look familiar? It's a typical note that has been scanned into a patient's electronic medical record. It was originally handwritten and includes a small schematic diagram of a tympanic membrane. But it could have been typed or dictated with a system such as Dragonspeak.
Does it seem skimpy? How does it compare to your own office records or those you receive from an emergency room? Is the format familiar?
You may wonder why I don't use the SOAP format (subjective, objective, assessment, plan). I was already a few steps into my training when SOAP was introduced and promoted. One of those old dog/new tricks deals. But a more philosophic answer is that I have some real reservations about the objectivity of most physical exams, my own included.
Look at our poor track record in observing and recording the appearance of tympanic membranes or heart murmurs or lung sounds. How many of us are disciplined enough to describe a skin eruption beyond reporting it as “maculopapular”? If we were to change the “O” in SOAP to “observation” instead of “objective,” I could buy it. Otherwise a physical exam is in the eye of the beholder. The only objective portions are the vital signs and the lab work. And I have my doubts about the accuracy of weights and BPs coming out of many offices and emergency rooms. My notes are divided into history, physical exam, diagnosis (or assessment), and plan. If the child has multiple problems, I number them and match them with similarly numbered plans.
If you can accept my old-school format, can you accept my note's skimpiness? You may ask, “Where are the pertinent negatives?” Good question. But here's a better question: What is the value of listing pertinent negatives?
When we were medical students, a list of pertinent negatives proved that we had taken a thorough history and done a complete exam. My colleagues who cover for me know how thoroughly I interview and examine patients. I owe them a thumbnail sketch of how sick the child looked and a description of the positives in case it's helpful for comparison at a subsequent visit. I include “chest clear” out of habit, but otherwise I try to spare my busy brother and sister pediatricians the tedium of a laundry list of negatives.
Two groups retain a perverse curiosity about what I haven't seen or heard: the lawyers and the third-party bean counters. They remain zealous believers in the myth that, “if you didn't document it, it did not happen.” Obviously this is rubbish, but they wield power (mostly financial), and unfortunately that power has influenced, and I fear will continue to influence, the format and style of electronic medical records. Templates, drop-down lists, and preprogrammed phrases will become the norm. The busy physician will click or tap with a stylus to create a voluminous list of negatives, pertinent and otherwise, that only a medical school instructor would care about.
Navigating these electronic shortcuts is not as easy as it sounds. The extensive lists they generate mean more wasted time for a covering physician. The finished note's spell-checked and laser-printed clarity doesn't guarantee that the right questions have been asked or that the exam was expertly done.
Hx: runny nose × 3 d—fever 101 ax yest afternoon—very fussy last night'some cough—no Breakfast—no V or D
PE: Well—N.A.D. sl fussy—orients to Mom—Chest clear—Rt TM honey colored opaque bulging—Lt creamy fluid level 2/3 immobile
Dx: B.O.M.
Plan: Amox 250 tid × 10 d/Ret 3 wks
Does this look familiar? It's a typical note that has been scanned into a patient's electronic medical record. It was originally handwritten and includes a small schematic diagram of a tympanic membrane. But it could have been typed or dictated with a system such as Dragonspeak.
Does it seem skimpy? How does it compare to your own office records or those you receive from an emergency room? Is the format familiar?
You may wonder why I don't use the SOAP format (subjective, objective, assessment, plan). I was already a few steps into my training when SOAP was introduced and promoted. One of those old dog/new tricks deals. But a more philosophic answer is that I have some real reservations about the objectivity of most physical exams, my own included.
Look at our poor track record in observing and recording the appearance of tympanic membranes or heart murmurs or lung sounds. How many of us are disciplined enough to describe a skin eruption beyond reporting it as “maculopapular”? If we were to change the “O” in SOAP to “observation” instead of “objective,” I could buy it. Otherwise a physical exam is in the eye of the beholder. The only objective portions are the vital signs and the lab work. And I have my doubts about the accuracy of weights and BPs coming out of many offices and emergency rooms. My notes are divided into history, physical exam, diagnosis (or assessment), and plan. If the child has multiple problems, I number them and match them with similarly numbered plans.
If you can accept my old-school format, can you accept my note's skimpiness? You may ask, “Where are the pertinent negatives?” Good question. But here's a better question: What is the value of listing pertinent negatives?
When we were medical students, a list of pertinent negatives proved that we had taken a thorough history and done a complete exam. My colleagues who cover for me know how thoroughly I interview and examine patients. I owe them a thumbnail sketch of how sick the child looked and a description of the positives in case it's helpful for comparison at a subsequent visit. I include “chest clear” out of habit, but otherwise I try to spare my busy brother and sister pediatricians the tedium of a laundry list of negatives.
Two groups retain a perverse curiosity about what I haven't seen or heard: the lawyers and the third-party bean counters. They remain zealous believers in the myth that, “if you didn't document it, it did not happen.” Obviously this is rubbish, but they wield power (mostly financial), and unfortunately that power has influenced, and I fear will continue to influence, the format and style of electronic medical records. Templates, drop-down lists, and preprogrammed phrases will become the norm. The busy physician will click or tap with a stylus to create a voluminous list of negatives, pertinent and otherwise, that only a medical school instructor would care about.
Navigating these electronic shortcuts is not as easy as it sounds. The extensive lists they generate mean more wasted time for a covering physician. The finished note's spell-checked and laser-printed clarity doesn't guarantee that the right questions have been asked or that the exam was expertly done.
Hx: runny nose × 3 d—fever 101 ax yest afternoon—very fussy last night'some cough—no Breakfast—no V or D
PE: Well—N.A.D. sl fussy—orients to Mom—Chest clear—Rt TM honey colored opaque bulging—Lt creamy fluid level 2/3 immobile
Dx: B.O.M.
Plan: Amox 250 tid × 10 d/Ret 3 wks
Does this look familiar? It's a typical note that has been scanned into a patient's electronic medical record. It was originally handwritten and includes a small schematic diagram of a tympanic membrane. But it could have been typed or dictated with a system such as Dragonspeak.
Does it seem skimpy? How does it compare to your own office records or those you receive from an emergency room? Is the format familiar?
You may wonder why I don't use the SOAP format (subjective, objective, assessment, plan). I was already a few steps into my training when SOAP was introduced and promoted. One of those old dog/new tricks deals. But a more philosophic answer is that I have some real reservations about the objectivity of most physical exams, my own included.
Look at our poor track record in observing and recording the appearance of tympanic membranes or heart murmurs or lung sounds. How many of us are disciplined enough to describe a skin eruption beyond reporting it as “maculopapular”? If we were to change the “O” in SOAP to “observation” instead of “objective,” I could buy it. Otherwise a physical exam is in the eye of the beholder. The only objective portions are the vital signs and the lab work. And I have my doubts about the accuracy of weights and BPs coming out of many offices and emergency rooms. My notes are divided into history, physical exam, diagnosis (or assessment), and plan. If the child has multiple problems, I number them and match them with similarly numbered plans.
If you can accept my old-school format, can you accept my note's skimpiness? You may ask, “Where are the pertinent negatives?” Good question. But here's a better question: What is the value of listing pertinent negatives?
When we were medical students, a list of pertinent negatives proved that we had taken a thorough history and done a complete exam. My colleagues who cover for me know how thoroughly I interview and examine patients. I owe them a thumbnail sketch of how sick the child looked and a description of the positives in case it's helpful for comparison at a subsequent visit. I include “chest clear” out of habit, but otherwise I try to spare my busy brother and sister pediatricians the tedium of a laundry list of negatives.
Two groups retain a perverse curiosity about what I haven't seen or heard: the lawyers and the third-party bean counters. They remain zealous believers in the myth that, “if you didn't document it, it did not happen.” Obviously this is rubbish, but they wield power (mostly financial), and unfortunately that power has influenced, and I fear will continue to influence, the format and style of electronic medical records. Templates, drop-down lists, and preprogrammed phrases will become the norm. The busy physician will click or tap with a stylus to create a voluminous list of negatives, pertinent and otherwise, that only a medical school instructor would care about.
Navigating these electronic shortcuts is not as easy as it sounds. The extensive lists they generate mean more wasted time for a covering physician. The finished note's spell-checked and laser-printed clarity doesn't guarantee that the right questions have been asked or that the exam was expertly done.