History and Physical limited because...

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Angry Birds said:
...because I don't give a sh**.

Is this a legit reason?

Mann, my bedside manner is fast deteriorating ...
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Physical exams are overrated. History is way overrated as most pts have no clue about their health. Everyone has Chest pain and 10/10 pain.

I had a guy yesterday with SOB/hypoxia tell me he had no heart/lunch issues. Healthy as a horse, cuts grass without issues. AF RVR on his EKG. Denied ever having a cardiac issue or even knew what AF was.

Looked at his medical records and he was admitted for AF RVR with Pulm edema 6 mo ago. Shocked that I brought that up.
 
emergentmd said:
Physical exams are overrated. History is way overrated as most pts have no clue about their health. Everyone has Chest pain and 10/10 pain.

I had a guy yesterday with SOB/hypoxia tell me he had no heart/lunch issues. Healthy as a horse, cuts grass without issues. AF RVR on his EKG. Denied ever having a cardiac issue or even knew what AF was.

Looked at his medical records and he was admitted for AF RVR with Pulm edema 6 mo ago. Shocked that I brought that up.
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95% of my burnout is the result of having to deal with patients like this.
 
Ya I have no idea why people cannot remember their lunch issues. Most of the time I let the patient talk until they stop. I kinda listen and then ask a few questions and go through a quick exam that takes 1 min and order workup.

Sent from my Pixel 2 using Tapatalk
 
^that said, I strongly disagree that the history & physical is overrated. My most satisfying diagnoses are usually made on history, and confirmed on physical exam. The test results are used to prove it to the consultants.

Now, I'm not trying to be all high & mighty here - I still order plenty of tests. Also, this article in press found that having received advanced imaging was one of the main determinants of patient satisfaction. But I still find the H&P to be indispensable. And when I go to the doctor for my care, I want them to do a good H&P, not just order a bunch of tests.
 
Most of it is just billing nonsense. That's why I have the scribe write it down. Honestly, HPI, ROS, FHx, SocHx are irrelevant for us when it comes to most patients, but necessary to bill the chart. Physical exam isn't helpful on most patients, but it does guide the workup on abdominal pain certainly.

Scribes are great at capturing all the crap that I don't even care about.
 
I can't believe someone posted this when they did.

All season, I've said things like: "All I'm doing is running an adult day-care", and "I'm not working to help people anymore; I'm working to help them in spite of themselves."
 
Mr. Hat said:
Oh man, thanks for starting this thread! Just last night I was thinking how I could generally spend 30 seconds in each room instead of however many minutes I usually spend, and it probably wouldn't make much of a difference. Actually it might help since everyone has chest pain and I'd be better off getting out of the room before they can start talking about it and my ****ing scribe writes it down 15 places in the chart. 19 y/o M presents with rash to feet after poison ivy exposure. ROS will no doubt be positive for crushing ripping chest pain radiating to the back. I swear.
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Yep. I had to quit using the scribes at my primary job site because of this.
The ICU-bound pneumonia patient? ROS = No cough. No dyspnea. No fever.
 
Mr. Hat said:
Oh man, thanks for starting this thread! Just last night I was thinking how I could generally spend 30 seconds in each room instead of however many minutes I usually spend, and it probably wouldn't make much of a difference. Actually it might help since everyone has chest pain and I'd be better off getting out of the room before they can start talking about it and my ****ing scribe writes it down 15 places in the chart. 19 y/o M presents with rash to feet after poison ivy exposure. ROS will no doubt be positive for crushing ripping chest pain radiating to the back. I swear.
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How are you guys doing ROS on the young and healthy bs people who you really don't believe their fake pan positive ROS? Like 19 yo F with Dysuria for 2 days who is there texting on their phone the whole time. The only thing that really matters is documenting an unremarkable abd exam, normal vitals, and negative pregnancy test. The charting people recently started complaining that I don't have enough ROS. I try to play the game of any recent infections (and I assume if they say no this covers fevers, runny nose, diarrhea, pink eye, cough which is 5 systems). For chest pain and dyspnea I say "and chest and breathing are ok?" Obviously I don't do this with older people or people who have never been to my ED before. What tricks do you guys have ? Pgy3 wanting to learn to maximize my time but still be thorough.
 
bravotwozero said:
This is why it's key to not pick up too many shifts. When I do that, especially consecutively, after the 4th shift in a row or so, every time a patient talks to me all I hear in my brain is 'shut up, shut up, shut up.....'
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Yep. I don't know how some of our posters on here can simply switch off the nausea and related symptoms that I get whenever I have to deal with the throbbing masses of dumb@sses that I have to deal with every shift.
 
Mr. Hat said:
Yeah that's the problem. A couple of ways around this:

First, and my personal favorite, is the rapid fire review of systems. "So any recent rashvisionchangeschestpaindyspneaabdominalpainheadachepeniledischargebleedingbruisingfatiguehomicidalthoughts"? And if you're worried they'll say "yes" to any of the rapid fire questions you start with "so I'm assuming no recent...."

Second is the implied ROS like you alluded to. "Any recent illnesses or injuries?" No = negative for fever, chills, eye discharge, sore throat, cough, vomiting, diarrhea, dysuria, MSK pain, bruising problems, etc etc.

Not that I would ever use either of these methods of course.
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Oh I like the part about recent injuries. Thanks
 
Last shift I had hysterical mommy with her eight year old after a head injury (totally fine) who was demanding CT brain; but "she heard you could shield him to protect him from radiation"; so she wanted that.

I don't want to live on this planet anymore.
 
RustedFox said:
Last shift I had hysterical mommy with her eight year old after a head injury (totally fine) who was demanding CT brain; but "she heard you could shield him to protect him from radiation"; so she wanted that.

I don't want to live on this planet anymore.
Click to expand...
"The best shield for the radiation from my CT scanner is the roof of your Honda Odyssey."
 
RustedFox said:
Last shift I had hysterical mommy with her eight year old after a head injury (totally fine) who was demanding CT brain; but "she heard you could shield him to protect him from radiation"; so she wanted that.

I don't want to live on this planet anymore.
Click to expand...

When I went into a room and the patient wasn't there, her husband said helpfully, "She's in the scat canner."
 
You want to jabber at me for 10 minutes and then make me stick my finger in your rectum? For $250? Okay, I guess so. You want me to explain 3 times why a CT scan on your kid is a bad idea? For $125? Okay. I'll do that too.

Seriously, from some of the comments in this thread you'd think people weren't making $400K a year just sitting on a little black rolley stool and talking to people instead of doing real work. You could be dealing with the same dumb people at the Wal-mart returns counter for $8 an hour. Or mowing lawns. Or fixing diesel engines in 30 degree weather.

While I can relate to all of the comments, the main thing I'm seeing is people who are working too many shifts and seeing too many patients per hour. Cut back to 100 hours a month and 2 patients per hour and it becomes a privilege to take care of people again. Even the dumb ones. And if you still don't like it, then go do something else. You're plenty smart. You know how to work hard. There are gobs of other things you could do with your life that will pay you. You're not trapped in medicine, at least not once you pay off your loans and realize you don't have to live the "doctor lifestyle" to be happy. In fact, there's a decent chance that you can even make more money and work less hard doing something else.

And the rapid-fire ROS should always end with "....or gonorrhea". Then you always get a "no" and you can move on.
 
The White Coat Investor said:
You want to jabber at me for 10 minutes and then make me stick my finger in your rectum? For $250? Okay, I guess so. You want me to explain 3 times why a CT scan on your kid is a bad idea? For $125? Okay. I'll do that too.

Seriously, from some of the comments in this thread you'd think people weren't making $400K a year just sitting on a little black rolley stool and talking to people instead of doing real work. You could be dealing with the same dumb people at the Wal-mart returns counter for $8 an hour. Or mowing lawns. Or fixing diesel engines in 30 degree weather.

While I can relate to all of the comments, the main thing I'm seeing is people who are working too many shifts and seeing too many patients per hour. Cut back to 100 hours a month and 2 patients per hour and it becomes a privilege to take care of people again. Even the dumb ones. And if you still don't like it, then go do something else. You're plenty smart. You know how to work hard. There are gobs of other things you could do with your life that will pay you. You're not trapped in medicine, at least not once you pay off your loans and realize you don't have to live the "doctor lifestyle" to be happy. In fact, there's a decent chance that you can even make more money and work less hard doing something else.

And the rapid-fire ROS should always end with "....or gonorrhea". Then you always get a "no" and you can move on.
Click to expand...

You're missing the point; its the loss of faith in humanity that makes it all so frustrating.

Oh. That, and you have a unicorn job. Prepare to hear that a bunch more.
 
The White Coat Investor said:
You want to jabber at me for 10 minutes and then make me stick my finger in your rectum? For $250? Okay, I guess so. You want me to explain 3 times why a CT scan on your kid is a bad idea? For $125? Okay. I'll do that too.

Seriously, from some of the comments in this thread you'd think people weren't making $400K a year just sitting on a little black rolley stool and talking to people instead of doing real work. You could be dealing with the same dumb people at the Wal-mart returns counter for $8 an hour. Or mowing lawns. Or fixing diesel engines in 30 degree weather.

While I can relate to all of the comments, the main thing I'm seeing is people who are working too many shifts and seeing too many patients per hour. Cut back to 100 hours a month and 2 patients per hour and it becomes a privilege to take care of people again. Even the dumb ones. And if you still don't like it, then go do something else. You're plenty smart. You know how to work hard. There are gobs of other things you could do with your life that will pay you. You're not trapped in medicine, at least not once you pay off your loans and realize you don't have to live the "doctor lifestyle" to be happy. In fact, there's a decent chance that you can even make more money and work less hard doing something else.

And the rapid-fire ROS should always end with "....or gonorrhea". Then you always get a "no" and you can move on.
Click to expand...

You always make me feel like a bad person.

On a serious note, just wanted to say I was googling like crazy just yesterday to figure out life insurance options, and each link i went to was useless until I came upon yours. You saved me lots of money. I was gonna buy something crappy and your article made me realize how crappy it was. Thanks!
 
WCI, for me the biggest cause of burnout is that stupid people get to complain. I can do everything right, explain 10X to a patient why X,Y,Z treatment is bad or not indicated, spend 20 minutes in the room and still get a complaint. The nonsense, BS complaints from dumb people who don't know any better are what crushes the soul, and makes me want to leave the specialty altogether.
 
GTP said:
How are you guys doing ROS on the young and healthy bs people who you really don't believe their fake pan positive ROS? Like 19 yo F with Dysuria for 2 days who is there texting on their phone the whole time. The only thing that really matters is documenting an unremarkable abd exam, normal vitals, and negative pregnancy test. The charting people recently started complaining that I don't have enough ROS. I try to play the game of any recent infections (and I assume if they say no this covers fevers, runny nose, diarrhea, pink eye, cough which is 5 systems). For chest pain and dyspnea I say "and chest and breathing are ok?" Obviously I don't do this with older people or people who have never been to my ED before. What tricks do you guys have ? Pgy3 wanting to learn to maximize my time but still be thorough.
Click to expand...

One key thing to remember is that for anything other than a level 5 chart, you do not need a 10 point ROS. Foot rash, dysuria, etc - none of these will be level 5 charts, so no need to do a deep dive ROS. "No fever, no penile discharge" will suit you just fine.
 
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GeneralVeers said:
WCI, for me the biggest cause of burnout is that stupid people get to complain. I can do everything right, explain 10X to a patient why X,Y,Z treatment is bad or not indicated, spend 20 minutes in the room and still get a complaint. The nonsense, BS complaints from dumb people who don't know any better are what crushes the soul, and makes me want to leave the specialty altogether.
Click to expand...

I agree it isn't fair. And I know you guys just come here to blow off some steam sometimes. But in the end, if someone wants to pay me $400K a year to write stupid complaints about me....okay, that's fine with me. 🙂 If you're not feeling medicine as a calling today, look at it as a job (i.e. it's not fun, in fact it's so bad that people have to be paid to do it). If it doesn't feel like a good job today, look at it as a calling. It'll make you feel better and reduce your burnout.
 
The White Coat Investor said:
You want to jabber at me for 10 minutes and then make me stick my finger in your rectum? For $250? Okay, I guess so. You want me to explain 3 times why a CT scan on your kid is a bad idea? For $125? Okay. I'll do that too.

Seriously, from some of the comments in this thread you'd think people weren't making $400K a year just sitting on a little black rolley stool and talking to people instead of doing real work. You could be dealing with the same dumb people at the Wal-mart returns counter for $8 an hour. Or mowing lawns. Or fixing diesel engines in 30 degree weather.

While I can relate to all of the comments, the main thing I'm seeing is people who are working too many shifts and seeing too many patients per hour. Cut back to 100 hours a month and 2 patients per hour and it becomes a privilege to take care of people again. Even the dumb ones. And if you still don't like it, then go do something else. You're plenty smart. You know how to work hard. There are gobs of other things you could do with your life that will pay you. You're not trapped in medicine, at least not once you pay off your loans and realize you don't have to live the "doctor lifestyle" to be happy. In fact, there's a decent chance that you can even make more money and work less hard doing something else.

And the rapid-fire ROS should always end with "....or gonorrhea". Then you always get a "no" and you can move on.
Click to expand...
I've tried the rapid fire ROS before and ended the statement with "rash?" Dude then spent another 10 mins trying to get me to diagnose a rash he had earlier this week that is no longer there on presentation. "But what could it have been " ... seriously ?
 
WilcoWorld said:
One key thing to remember is that for anything other than a level 5 chart, you do not need a 10 point ROS. Foot rash, dysuria, etc - none of these will be level 5 charts, so no need to do a deep dive ROS. "No fever, no penile discharge" will suit you just fine.
Click to expand...
The chart gods sent me a stupid template recently and this is not necessarily true. Some complaints require 2,3 or 5 ROS. It's just difficult to know which complaints they think falls under which categories. So I've been trying to hit ten systems for anyone sick enough to be admitted and 5 for others. I think any recent infections, are you eating okay, breathing okay and peeing/pooping okay should cover 5 systems. I really hate that this a thing. I spend more time charting and fighting with the computer to print discharge instructions than taking care of patients
 
Review of systems is for medical students.
I treat history taking like ordering investigations - how will asking this question change my management?
 
WilcoWorld said:
One key thing to remember is that for anything other than a level 5 chart, you do not need a 10 point ROS. Foot rash, dysuria, etc - none of these will be level 5 charts, so no need to do a deep dive ROS. "No fever, no penile discharge" will suit you just fine.
Click to expand...
Exactly. This is not well taught in some residency programs. I sat down with a coder third year to discuss stuff like this.

Standard laceration (not polytrauma)? It's not a level 5, much of the billing comes from the lac repair. 2-9 system ROS (i.e. just the skin, neuro, msk questions you asked in the useful HPI).
 
GTP said:
The chart gods sent me a stupid template recently and this is not necessarily true. Some complaints require 2,3 or 5 ROS. It's just difficult to know which complaints they think falls under which categories. So I've been trying to hit ten systems for anyone sick enough to be admitted and 5 for others. I think any recent infections, are you eating okay, breathing okay and peeing/pooping okay should cover 5 systems. I really hate that this a thing. I spend more time charting and fighting with the computer to print discharge instructions than taking care of patients
Click to expand...

Either I'm wrong or your coders are wrong. Here it is directly from cms.org: "An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number (two to nine) of additional systems."

I read that to mean that 2 systems gets me to an "extended ROS", and you only need a "complete ROS" when you're going for E/M level 5. That said, I acknowledge that there is some ambiguity in the above quote & I could be misinterpreting it. In any case, I've been documenting this way for over 5 years and my coders have never asked me to increase my ROS numbers. But I'm not an expert on this. If anyone has well-sourced, clearly stated information that contradicts my interpretation of the CMS website, please do correct me.
 
"Any fever, pain, or bleeding?"

that gets you 10+ systems.

I put the relevant ones in the HPI. For example, you come in with a fever I'm going to ask about sore throat, cough, rash, n/v/d, dyrusia, belly pain in the HPI.

If you come in with chest pain, I'm surely going to ask cough, dyspnea, leg swelling, recent trauma.

You can do a level 5 chart in 6 questions--
"what brings you into the ER today?" [HPI]
"Aside from what we just discussed, any other new/severe fever pain or bleeding in the past week?" {RoS}
"do you have any serious medical problems?" [its lovely if they say "I come here all the time look in the computer"] {PmhX}
"what medications do you take? (oh you just gave the list to the RN? thanks I'll look at that!)" [this is how I actually determine the PMHx]
"Any allergies to medications?" {allergies}
"Do you smoke?" {soc Hx}

Of course I might add on actual/relevant questions like a real doctor and all, but this is my routine template for a generic room with a vague complaint or bounce bag or odd patient who can't tell me details.

And if the RN got into the room before me and got the Meds/allergies/smoking I can just repeat them back to the patient and verify them, taking away all of those questions.

And yes, if just 1/3 of your patients are nice, normalish, kindish, and vaguely thankful for your help it makes the entire shift better.
 
WilcoWorld said:
Either I'm wrong or your coders are wrong. Here it is directly from cms.org: "An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number (two to nine) of additional systems."

I read that to mean that 2 systems gets me to an "extended ROS", and you only need a "complete ROS" when you're going for E/M level 5. That said, I acknowledge that there is some ambiguity in the above quote & I could be misinterpreting it. In any case, I've been documenting this way for over 5 years and my coders have never asked me to increase my ROS numbers. But I'm not an expert on this. If anyone has well-sourced, clearly stated information that contradicts my interpretation of the CMS website, please do correct me.
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Idk man. They didn't complain in first and second year. I only started getting complaints since mid year pgy3 and I've been doing everything the same for the last 2 years. My ros templates for major complaints haven't changed. I only used to ask questions that were relevant to the complaint, but this wasn't enough. My very first patient encounter after the complaint was so awkward. I had to ask a chest painer if he had any pink eye lately. The nurse gave me the dirtiest look. It was either that or headache lol
 
BoardingDoc said:
ROS for everyone: any fever, pain, swelling or cough? That gets 10 ros. Pain gives you
Headache
Back pain
Eye pain
Sore throat
Chest pain
Abdominal pain
Dysuria

Fever, swelling and cough get you the rest. Done. Now on to actual medicine.
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They claim this is fraud though and that insurance companies often send in "fake patients"
 
I have worked places where all charts documented to level 5.
Where they all coded and sent to ins co as level 5? No. Billing Co coded appropriately for the visit.
Worked at a ship for three years with that and never once had any issues.

I do similar to above so that if anyone cared to question I can always say I went through the ros.
The ros is the only limiting factor in billing as even a visual-only can get you a full PE😉


Sent from my iPhone using Tapatalk
 
I've had a few patients complain that their charts are inaccurate when they go online and read the physical exam section because they dont understand the language I am using or there is some minor inaccuracy (like hearing normal bilaterally when they are hard of hearing on one side or no tonsillar exudate when tonsils are removed in a visit for chest pain).

It's the way if the future--patients auditing all the useless information I have to record to bill insurance appropriately. The care I provide is secondary to documentation
 
chessknt87 said:
I've had a few patients complain that their charts are inaccurate when they go online and read the physical exam section because they dont understand the language I am using or there is some minor inaccuracy (like hearing normal bilaterally when they are hard of hearing on one side or no tonsillar exudate when tonsils are removed in a visit for chest pain).

It's the way if the future--patients auditing all the useless information I have to record to bill insurance appropriately. The care I provide is secondary to documentation
Click to expand...

I've had this happen, too.
It was the "sentinel event" that made me have to quit using scribes, as they were so bad that they were dangerous.

I said aloud to a scribe at the end of an H&P this sentence, to be dictated in the chart: "There is no prior EKG available for comparison."
What did she write? - "The prior troponin is unavailable for compared."
 
BoardingDoc said:
ROS for everyone: any fever, pain, swelling or cough? That gets 10 ros. Pain gives you
Headache
Back pain
Eye pain
Sore throat
Chest pain
Abdominal pain
Dysuria

Fever, swelling and cough get you the rest. Done. Now on to actual medicine.
Click to expand...

People tend to say yes to pain if you ask. Ask if they are bleeding from anywhere. No?

No hemoptisis
No hematemesis
No epistaxis
No hematuria
No bloody stools
No bleeding wounds

I try to avoid pain question in ROS unless I think it’s pertinent but then that is usually covered during normal history taking I guess.

I love the idea of rapid fire ending in gonorrhea though!
 
BoardingDoc said:
Who is "they" and how is it fraud?
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My current residency er director. But I'm sure that's what they all do. I've never seen an attending spend more than 2 mins in a room. 4 mins on days we are excused from the ed for didactics and they are working alone
 
littlejuan said:
People tend to say yes to pain if you ask. Ask if they are bleeding from anywhere. No?

No hemoptisis
No hematemesis
No epistaxis
No hematuria
No bloody stools
No bleeding wounds

I try to avoid pain question in ROS unless I think it’s pertinent but then that is usually covered during normal history taking I guess.

I love the idea of rapid fire ending in gonorrhea though!
Click to expand...
Oh this bleeding question is gold. I'm learning so much from you guys
 
littlejuan said:
People tend to say yes to pain if you ask. Ask if they are bleeding from anywhere. No?

No hemoptisis
No hematemesis
No epistaxis
No hematuria
No bloody stools
No bleeding wounds

I try to avoid pain question in ROS unless I think it’s pertinent but then that is usually covered during normal history taking I guess.

I love the idea of rapid fire ending in gonorrhea though!
Click to expand...

Agreed.

Which is why I always make sure to say any "new pain, swelling, or bleeding."

Otherwise patients start telling me about the headache or sore throat they had last month.
 
GeneralVeers said:
WCI, for me the biggest cause of burnout is that stupid people get to complain. I can do everything right, explain 10X to a patient why X,Y,Z treatment is bad or not indicated, spend 20 minutes in the room and still get a complaint. The nonsense, BS complaints from dumb people who don't know any better are what crushes the soul, and makes me want to leave the specialty altogether.
Click to expand...

So I've heard from an unconfirmed source that if you put 'anxiety reaction' as a diagnosis upon discharge, those patients don't get a patient satisfaction survey. Anyone know if this is true? Obviously you can't do that with everyone, but could prove to be enormously useful...
 
Gotta be honest guys. I just click rest of systems negative. I feel that’s easier to defend than clicking specific things as negative.

“The patient did not complain of any of these other symptoms while I was in the room” is different than denying them.

But my specific EMR doesn’t say that I reviewed it. It’s a thin defense I know.
 
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bravotwozero said:
So I've heard from an unconfirmed source that if you put 'anxiety reaction' as a diagnosis upon discharge, those patients don't get a patient satisfaction survey. Anyone know if this is true? Obviously you can't do that with everyone, but could prove to be enormously useful...
Click to expand...

Its not. I can dig up the latest PG info sheet on my hard drive. It specifically addresses this, adding that these patients should not be excluded.
 
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