Can You Say "Duh"!
Specialists; gotta love 'em (and their EMRs, too.)
Excerpts from specialist's letter:
Past Surgical History: appendectomy, cholecystectomy, oophorectomy, thyroidectomy, back surgery
Physical Exam:
Neck: trachea midline, scar from previous thyroid surgery, no obvious thyroid enlargement
Thank goodness!
(Now don't go getting your diapers in a bunch. I know you can do a partial thyroidectomies where some of the gland is left that can potentially hypertrophy later. In general, though, that would be specified as "partial", even though to be precise he should have specified a total thyroidectomy, which is what she'd had. Still, this was a non-surgical, non-endocrine specialist and the documentation was probably boilerplate.)
posted by #1 Dinosaur @ 5:43 PM
7 comments
7 Comments:
That's quite funny. Our office is starting an EMR on Monday...sadly I'm sure I will be making similar mistakes.
Ah ... but aren't the EMRs supposed to improve care?
Similar to when templates say that an 18 month old is "alert and oriented x 3" or when post-irridectomy patients are documented on templates as having "PERRLA."
This is my boggest problem with the EMR - Exams and text that "Pop in", leaving the doc to erase the non-relevent portions, as opposed to using check off boxes to force positive responses.
One of these days it's going to come back and haunt us.
Speaking as an MT, you'd be really suprised (or maybe not) how many doctors don't pay attention when they dictate. I see it every day.
REVIEW OF SYSTEMS:
ENDOCRINE: No history of diabetes or hypothyroidism.
MEDICATIONS:
1. Aspirin.
2. Synthroid.
Sometimes it's good to have an MT on your side.
I would have flagged the review of systems and medications for the doctor (depending on the assessment/impression indicating hypothyroidism).
Yup, boiler plate. And about useless. And you can bet your bippy that it'll come back to bite you, think lawyers can't read all that fine lovely print?
I was going to leave a long comment on the death of the useful medical record and its replacement with the waste of time that is boilerplate verbiage aimed at satisfying the Medicare auditors. But your other readers beat me to it.
There was a specialist whose reports seemed to have at the end of every paragraph a statement such as unless positive findings noted elsewhere.
Seemed over boilerplated but probably there as an out.
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