History and Physical limited because...

[bravotwozero]

Dammit...


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[Apollyon]

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...

I think those are set by individual facility contracts, so, at one shop, psychs don't get them, but, at another, every single (literal) stinking pt gets a survey. The worst are even the LWBS and elopers.

 

[The White Coat Investor]

Our psychs don't get our surveys. But ours aren't press ganey surveys either.

 

[Apollyon]

Our psychs don't get our surveys. But ours aren't press ganey surveys either.

Are they home built, Gallup, or another commercial one?

 

[The White Coat Investor]

Are they home built, Gallup, or another commercial one?

Can't remember. Name the other big players and I can probably recognize it. It's commercial.

 

[TooMuchResearch]

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."

I'm sorry about the poor quality of scribes. Ours are trained and employed by the group, and there are still only a few that really help me.

 

[Angry Birds]

"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.

Pain, fever, or bleeding. I like it. That’s smart.

But dude, you still make the rookie mistake of asking patients what meds they are on? You’ll be there forever, especially when they reach for their bag.

The nurse asks this question and inputs them in the chart. So why the need to ask this? All the time you saved from the three question trick lost.

 

[WilcoWorld]

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.

Dammit...


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Yep, what Apollyon said.

 

[Arcan57]

They claim this is fraud though and that insurance companies often send in "fake patients"

And if you’re naughty Krampus will steal you away and eat you.

 

[Janders]

Pain, fever, or bleeding. I like it. That’s smart.

But dude, you still make the rookie mistake of asking patients what meds they are on? You’ll be there forever, especially when they reach for their bag.

The nurse asks this question and inputs them in the chart. So why the need to ask this? All the time you saved from the three question trick lost.

Your point is valid and to be honest I was dumbing down my actual questions to make a streamlined post. Once I get this all typed out we can make a fancy flow chart.

If the RN already made it in, I'm sure as hell reading the data they collected. Then I like to walk in the room at tell the patient directly "The nurse who spoke with you earlier told me about your medical history and I reviewed your list of medications" and mention any pertinent details, such as "she tells me you've been vomiting 17x an hour every since you had that bottomless stein-of-eggnog special yesterday" or "I heard you have horrible penile discharge and the Doxycycline isn't helping?" I think this builds immediate trust and creates the impression the nurses and I are well-oiled healthcare machine.

What I really do, assuming I haven't already chart-dived the last discharge summery or the RN didn't beat me into the room, and I'm really taking a full brand new history-->

I ask Do you have any medical problems?

If Yes, I accept their list. If their list starts "58 years ago, I caught a cold while ice skating..." I quickly juke right cut left and run out of the room to the resus bay.

If No and they look young/healthy, I then ask the combo question of "any medication you take every day or major surgery in the past?" mostly to catch any medical problem they forgot to mention.

If No, and I think there is no way on God's green earth the cachectic 85yo with a PICC line in front of me has "no medical problems" I ask for their list of medications. If they pull out a sheet of paper, I am happy and glance at it to cover their major diagnoses and hand it to the nice RN. If they pull out the tripled-bagged gallon ziplock that appears to have, at the least, 10 redundant and largely expired bottles of Rx Vitamin D I smile really big and hand it to the nice RN. They, of course, love this.

 

[RustedFox]

If they pull out the tripled-bagged gallon ziplock that appears to have, at the least, 10 redundant and largely expired bottles of Rx Vitamin D I smile really big and hand it to the nice RN. They, of course, love this.

Oh my God, they all DO have eleventeen varieties of vit.D in a plastic bag. Soooo true.
That, and four varieties of aspirin.

 

[doctalaughs]

Oh my God, they all DO have eleventeen varieties of vit.D in a plastic bag. Soooo true.
That, and four varieties of aspirin.

Ha -you guys have a funny thread. At least they dont bring a gallon ziplock of every lotion they have used on *every* body part for the past 20 years along with a smaller ziplock of the hair they have been collecting that is falling out (I’m in derm).

 

[Perfect Hair Day]

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.

10/10 pain 85% se and 99% sp for dilaudidopenia

 

[RustedFox]

This is seriously my patient list for tonight. 10 hours, 22 patients - not counting MLP supervision/input.

Ready? Go. In no particular order, because I can't get CERNER to sort it like that.

1. Forty-ish female. Cough x 3 months. Won't stop smoking. Nuuu Yawwwk. 2 rounds of antibiotics from dip**** primary nurse practitioner. "Dere's fluid on my lungs, dey say, dawwwk."
No cough on exam at all. Won't shut up despite claims of dyspnea. CXR negative. "What about my Cholesterawwwl, dawwwk? Why didntchu TEST faw daat? What kinda'a dawwktah aaah you'se, dawwwk?" Bye.

2. 24 year old male. I like heroin. My mommy brought me here. She wipes my @ss when I'm done pooping. I still don't have a job. Only poor people wear denim. I have an abscess in my left antecubital. It hurts reaaaal baaad. What do you MEAN you can't ADMIT him for his PROBLEM ?!? Incised/drained. I made sure to wave the kerlex soaked in foul-smelling pus by his nose *inadvertently*. Kthxbye. Please go do your drugs in your rich daddy's friend's home next time. Also; consider employment or overdose; your choice. Overdose might be better, son.

3. 40 year old female. Allergic reaction. Urticarial rash. Took a shower; it went away. But... what WAS it, doc? No way to tell. No rash. Bye.

4. 40 year old male. Fever. Obvious trackmarks on left arm and chest. Tries to tell me that its from a "welding torch and brush". I leaned on him after 45 mintues. "Dude, I'm not a cop. I don't even like cops. What are you using?" - "Heroin, doc. All day, every day." Guy is actually septic; but thanks for trying your luck at the "lets lie to the doc game". Admit.

5. 50 year old male. Nausea/vomiting from seafood buffet... but.... the vomiting made my chronic back pain act up. Only thing that works is Dilaudid. I live in Ohio. Where? Marietta.. no, Fremont.. no, Findlay.... Exam negative. Discharged.

6. 21 year old female. "Autism Spectrum Disorder", which means "I don't want to grow up and take responsibility for anything". Won't speak during exam. Mommy answers all questions. Sore throat. I look in throat. Stone cold normal. Mommy says she's coughing and has fever. No cough, no fever. Won't put down cellphone, frequently "talks" to BB-8 droid plush during exam in beeps and boops. My dad would have slapped me; and he would have been right to do so. Discharged.

7. 2 year old female. Mommy: "She had a fever when she came back from her daddy house!!! She won't eat nuthin'!!!" No fever. No cough. Happily eating popsicle. "Whatchoo MEAN you wont give mah baby an x-ray?!? Is we not important? Black lives MATTER!" CXR ordered. Child has still not coughed, nor displayed fever. Discharged. Will field patient complaint for this one. Thanks for the unnecessary visit and x-ray. Your child hates you.

8. SIGNOUT FROM OFF-GOING DOC: 50 year old female. 4 lumbar surgeries in the past year. Still with low back pain and now "New foot drop and incontinence!!!" We go to do signout at bedside. Patient not in room. ***FLUSSSH!!!*** Patient walks back from bathroom. We both see this. No foot drop. No incontinence (seeing as how she just pee'd). MRI negative. Call to neurosurgery.... "Oh... THIS gal?!" "What is she telling you NOW?" My finger up her bum. Normal tone. Discharged. "Can I have a shot of Dilaudid before I go?" - "No."

9. 84 year old female. Fever/chills, dry cough. Flu positive. "Thank you, young man. Can I please go home now? I don't want to be a burden." Do you want some medicine, grandma? ... - "No, I figure that I'll be just fine. I have Tylenol at home. Thank you. Thank you. Thank you."

10. 23 year old male. Crohn's Disease. Hands me last colonoscopy. Minimal involvement of anything. No belly pain. "Why are you here?" - "I'm here because my naturopath told me to come here for 'IV nutrients'." - No joke... that's actually what he said. Labs all normal. Discharged. *** YOUR NATUROPATH TOLD YOU TO COME HERE FOR IV NUTRIENTS ?!? WHAT... WAS A POULTICE OF HERBS CONTRAINDICATED?!? ***

11. 52 year old female. JUST discharged 3 hours ago with diverticulitis. "I pooped again. There was blood. I didn't know what to do, so I came back." - Did you pick up your cipro/flagyl and the rest of the supportive meds? "No." Discharged.

12. 36 year old male. "I pooped twice today. There was blood. I usually only poop once. I have internal hemorrhoids." Also; I only poop once before I finish playing Final Fantasy III on SNES... by 2pm. I never poop twice, and never by the time I finish that part of the game. Guy is 5-foot-5 by 5-foot-5 by 5-foot-5. Can't breathe with his mouth closed. That's all I need to hear. Rectal negative. Hemoocult negative. Discharged.

13. 3 year old hit head on trampoline at local "trampoline park". Got out phone, worked thru PECARN algorithm with mommy at bedside (Thanks, MDCalc!) Mommy: "But.... aren't you doing to do some TESTING?!" We juuuust did that, mommy. Discharged.

14. Glass coffee tabletop pulled down on 2 year old's feet. Crush injury. X-rays negative. Child can be sent home... with his two parents that smell like weed and are too busy asking for more chips to listen to anything I have to say.

15. 19 year old female. Pelvic pain x 3 months. "Have you seen anyone else about this?" - No. - Review of records reveals 2 visits this month for identical complaints, both with negative workups and CT abd/pelvis or ultrasound. Exam stone cold negative. Whole room smells like weed when I walk in. I order necessary testing. No imaging. I walk back in to review results. Somehow; smell of weed is waaay stronger, dude. "I'm not pregnant?! Thanks." I walk out, head to cafeteria. No french fries? Bummer. Cafeteria gal makes me a sandwich because I *looked hungry*. Thanks, Debbie! I love you, and your face, and howaboutItellyouaboutthetimewhereIwalkedintothecafeteriaandyouwerelike!whoa!!

16. 72 year old female. Fat. Hypertensive. Diabetic. Hyperlipidemic. Smoker. Family history CAD+. Chest pain. Admitted in 20 minutes or less.

The other six don't matter... it was either "nonspecific fall in a demented 90+ year old female" or "slam dunk chest pain r/out ACS".

 

[Apollyon]

This is seriously my patient list for tonight. 10 hours, 22 patients - not counting MLP supervision/input.

Ready? Go. In no particular order, because I can't get CERNER to sort it like that.

1. Forty-ish female. Cough x 3 months. Won't stop smoking. Nuuu Yawwwk. 2 rounds of antibiotics from dip**** primary nurse practitioner. "Dere's fluid on my lungs, dey say, dawwwk."
No cough on exam at all. Won't shut up despite claims of dyspnea. CXR negative. "What about my Cholesterawwwl, dawwwk? Why didntchu TEST faw daat? What kinda'a dawwktah aaah you'se, dawwwk?" Bye.

2. 24 year old male. I like heroin. My mommy brought me here. She wipes my @ss when I'm done pooping. I still don't have a job. Only poor people wear denim. I have an abscess in my left antecubital. It hurts reaaaal baaad. What do you MEAN you can't ADMIT him for his PROBLEM ?!? Incised/drained. I made sure to wave the kerlex soaked in foul-smelling pus by his nose *inadvertently*. Kthxbye. Please go do your drugs in your rich daddy's friend's home next time. Also; consider employment or overdose; your choice. Overdose might be better, son.

3. 40 year old female. Allergic reaction. Urticarial rash. Took a shower; it went away. But... what WAS it, doc? No way to tell. No rash. Bye.

4. 40 year old male. Fever. Obvious trackmarks on left arm and chest. Tries to tell me that its from a "welding torch and brush". I leaned on him after 45 mintues. "Dude, I'm not a cop. I don't even like cops. What are you using?" - "Heroin, doc. All day, every day." Guy is actually septic; but thanks for trying your luck at the "lets lie to the doc game". Admit.

5. 50 year old male. Nausea/vomiting from seafood buffet... but.... the vomiting made my chronic back pain act up. Only thing that works is Dilaudid. I live in Ohio. Where? Marietta.. no, Fremont.. no, Findlay.... Exam negative. Discharged.

6. 21 year old female. "Autism Spectrum Disorder", which means "I don't want to grow up and take responsibility for anything". Won't speak during exam. Mommy answers all questions. Sore throat. I look in throat. Stone cold normal. Mommy says she's coughing and has fever. No cough, no fever. Won't put down cellphone, frequently "talks" to BB-8 droid plush during exam in beeps and boops. My dad would have slapped me; and he would have been right to do so. Discharged.

7. 2 year old female. Mommy: "She had a fever when she came back from her daddy house!!! She won't eat nuthin'!!!" No fever. No cough. Happily eating popsicle. "Whatchoo MEAN you wont give mah baby an x-ray?!? Is we not important? Black lives MATTER!" CXR ordered. Child has still not coughed, nor displayed fever. Discharged. Will field patient complaint for this one. Thanks for the unnecessary visit and x-ray. Your child hates you.

8. SIGNOUT FROM OFF-GOING DOC: 50 year old female. 4 lumbar surgeries in the past year. Still with low back pain and now "New foot drop and incontinence!!!" We go to do signout at bedside. Patient not in room. ***FLUSSSH!!!*** Patient walks back from bathroom. We both see this. No foot drop. No incontinence (seeing as how she just pee'd). MRI negative. Call to neurosurgery.... "Oh... THIS gal?!" "What is she telling you NOW?" My finger up her bum. Normal tone. Discharged. "Can I have a shot of Dilaudid before I go?" - "No."

9. 84 year old female. Fever/chills, dry cough. Flu positive. "Thank you, young man. Can I please go home now? I don't want to be a burden." Do you want some medicine, grandma? ... - "No, I figure that I'll be just fine. I have Tylenol at home. Thank you. Thank you. Thank you."

10. 23 year old male. Crohn's Disease. Hands me last colonoscopy. Minimal involvement of anything. No belly pain. "Why are you here?" - "I'm here because my naturopath told me to come here for 'IV nutrients'." - No joke... that's actually what he said. Labs all normal. Discharged. *** YOUR NATUROPATH TOLD YOU TO COME HERE FOR IV NUTRIENTS ?!? WHAT... WAS A POULTICE OF HERBS CONTRAINDICATED?!? ***

11. 52 year old female. JUST discharged 3 hours ago with diverticulitis. "I pooped again. There was blood. I didn't know what to do, so I came back." - Did you pick up your cipro/flagyl and the rest of the supportive meds? "No." Discharged.

12. 36 year old male. "I pooped twice today. There was blood. I usually only poop once. I have internal hemorrhoids." Also; I only poop once before I finish playing Final Fantasy III on SNES... by 2pm. I never poop twice, and never by the time I finish that part of the game. Guy is 5-foot-5 by 5-foot-5 by 5-foot-5. Can't breathe with his mouth closed. That's all I need to hear. Rectal negative. Hemoocult negative. Discharged.

13. 3 year old hit head on trampoline at local "trampoline park". Got out phone, worked thru PECARN algorithm with mommy at bedside (Thanks, MDCalc!) Mommy: "But.... aren't you doing to do some TESTING?!" We juuuust did that, mommy. Discharged.

14. Glass coffee tabletop pulled down on 2 year old's feet. Crush injury. X-rays negative. Child can be sent home... with his two parents that smell like weed and are too busy asking for more chips to listen to anything I have to say.

15. 19 year old female. Pelvic pain x 3 months. "Have you seen anyone else about this?" - No. - Review of records reveals 2 visits this month for identical complaints, both with negative workups and CT abd/pelvis or ultrasound. Exam stone cold negative. Whole room smells like weed when I walk in. I order necessary testing. No imaging. I walk back in to review results. Somehow; smell of weed is waaay stronger, dude. "I'm not pregnant?! Thanks." I walk out, head to cafeteria. No french fries? Bummer. Cafeteria gal makes me a sandwich because I *looked hungry*. Thanks, Debbie! I love you, and your face, and howaboutItellyouaboutthetimewhereIwalkedintothecafeteriaandyouwerelike!whoa!!

16. 72 year old female. Fat. Hypertensive. Diabetic. Hyperlipidemic. Smoker. Family history CAD+. Chest pain. Admitted in 20 minutes or less.

The other six don't matter... it was either "nonspecific fall in a demented 90+ year old female" or "slam dunk chest pain r/out ACS".

Unless you are getting legit $400/hr, you ain't paid enough.

 

[BAM!]

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.

I always learned that by clicking the ROS Neg button you're opening yourself up to legal risk. It implies you did a 12 point review of systems and everything was negative. When the lawyers ask if you discussed various items from each system and you fumble for an answer, it will look bad. Better to write down specific negatives.

 

[KGflyboy]

I always learned that by clicking the ROS Neg button you're opening yourself up to legal risk. It implies you did a 12 point review of systems and everything was negative. When the lawyers ask if you discussed various items from each system and you fumble for an answer, it will look bad. Better to write down specific negatives.

I considered this point of view as well but ended up concluding this probably isn't any less dubious than documenting specific findings for each system that may or may not be accurate.

With rapid fire ROS questions or premade templates, everyone will end up incorrectly documenting findings as negative because tye question was neither posed to the patient or not asked in a specific enough way to elicit the most accurate response. If you documented something as specifically negative, it better have been specifically asked.

If you ask a patient if they have any bleeding problems and then document "no hematemesis, no hemoptysis, no melena, no hematochezia, can you be sure tye patient isn't crapping black tar? I guess you can be pretty sure if you specifically asked about all of these things, but I don't think this is consistently done for every patient despite what people ma be documenting. Your practice pattern may be different, and if so, great job.

Ultimately I think documenting a ton of negative ROS findings you didn't specifically inquire about will make you look worse in court that documenting "ROS otherwise negative" even if you fumble for an answer. My answer in court would be as someone already stated. "The patient did not report any of those things to me." While not a rock solid defense, it sure beats documenting a negative finding which was clearly positive in retrospect, which I think happens routinely.

 

[emergentmd]

Charting's only goal is for billing and telling YOUR story.

Anyone who charts exactly what a patient says is lying to themselves. I bet no doctor's chart is like a court reporter. If you truly chart only what the patient says, then you will be the slowest doctor or softest doctor. But you will definitely not be a good doctor.

20 YO healthy pt without any medical history/risk factor, normal vitals, normal workup- I have chest pain (while texting his friends and drinking a soda)

me - ok, describe your chest pain

pt - Its crushing, heavy sensation and my left arm is numb with shortness of breath

me - Ok, lets get some test going to make sure nothing serious is going on.

My note will say. 20 YO healthy male, no medical hx/risk factor, with sharp localized chest pain, nonradiating without any SOB, diaphoresis worse with touching his chest. ALL other ROS neg.
Physical - everything neg except for reproducible chest pain to palpation

discharged with costoconditits.

Is any doctor really going to state in their note that the pt has crushing heavy chest pain with left arm numbness & SOB?

If so, you are going to admit all of your patients with chest pain.

 

[LaBusqueda]

Charting's only goal is for billing and telling YOUR story.

Anyone who charts exactly what a patient says is lying to themselves. I bet no doctor's chart is like a court reporter. If you truly chart only what the patient says, then you will be the slowest doctor or softest doctor. But you will definitely not be a good doctor.

20 YO healthy pt without any medical history/risk factor, normal vitals, normal workup- I have chest pain (while texting his friends and drinking a soda)

me - ok, describe your chest pain

pt - Its crushing, heavy sensation and my left arm is numb with shortness of breath

me - Ok, lets get some test going to make sure nothing serious is going on.

My note will say. 20 YO healthy male, no medical hx/risk factor, with sharp localized chest pain, nonradiating without any SOB, diaphoresis worse with touching his chest. ALL other ROS neg.
Physical - everything neg except for reproducible chest pain to palpation

discharged with costoconditits.

Is any doctor really going to state in their note that the pt has crushing heavy chest pain with left arm numbness & SOB?

If so, you are going to admit all of your patients with chest pain.

Gold star!
At my current gig we see a ton of dramatic, very young, very healthy, pts that dramatically present.

Often I feel like they are a set-up Pt/hidden-shopper type. Like- they were rehearsed with ultra classic symptoms of bad stuff and come in reciting it perfectly.
This has increased for me a lot over the pas few years. Really didn’t have the amount of this before.

But to your point, you really HAVE to editorialize in some cases.



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[The White Coat Investor]

This is seriously my patient list for tonight. 10 hours, 22 patients - not counting MLP supervision/input.

Ready? Go. In no particular order, because I can't get CERNER to sort it like that.

That's a fun post. We should all do that sometime. It gives a very clear description of what EM actually is. But bear in mind, any specialty could do that and make it look pretty bad. There's a fair amount of room for editorial comment. For example, consider these two patients I saw last night:

# 1

"45 year old whiney male gives himself his own allergy shots. Didn't bother for a couple of weeks because he got busy with the holidays. Then screws it up when he does do it over the holiday weekend when his allergist who doesn't even answer the phone can't see him for days and it is the busiest day of the year in the ER. He probably gave it intravascularly. His face gets a little red, so he takes some benadryl and a leftover steroid pill and calls the ER, demands to speak to the physician on duty, tells me he's driving in and wants me, a nurse, and medication waiting for him on arrival."

# 2

"Staff physician nearly dies but makes a last ditch effort to get to the closest source of epinephrine, barely squeaking out a call to the ED to give them 3 minutes of warning. I coordinate the best possible emergency care with pharmacy staff and nursing staff. On arrival, he is clearly anaphylactic and minutes from death. We rush him into room 1, attach him to a monitor, and slam IM epinephrine into him. The nurse slickly places an IV in seconds and we load him with an H1 blocker, an H2 blocker, and a steroid. He requires a second dose of epi, but then makes a rapid recovery. The patient, his teenager and his wife are intensely grateful for the excellent care received and thank all of the staff multiple times. In fact, they had already thanked the physicians and PAs with a thoughtful Christmas gift a few days before that my kids really liked. It was my pleasure to write the bill off, an option allowed to me as the owner of my business rather than a CMG employee. He will likely continue to refer patients to our ED for years to come and leaves an hour after his impending death was averted with a new-found respect for seasonal allergy shots, the miracle of modern medicine, and the competence of our ED and its staff."

As you can probably tell, it was the same patient. It's all in the presentation/attitude toward what you're doing. If you look for the crappy stuff about your job, you'll find it. There is plenty of it there. But if you look for the little miracles and differences you make that happen all the time, you'll find those too.

Sorry if I just made you feel guilty again, but I wanted to provide another perspective.

 

[BAM!]

That's a fun post. We should all do that sometime. It gives a very clear description of what EM actually is. But bear in mind, any specialty could do that and make it look pretty bad. There's a fair amount of room for editorial comment. For example, consider these two patients I saw last night:

# 1

"45 year old whiney male gives himself his own allergy shots. Didn't bother for a couple of weeks because he got busy with the holidays. Then screws it up when he does do it over the holiday weekend when his allergist who doesn't even answer the phone can't see him for days and it is the busiest day of the year in the ER. He probably gave it intravascularly. His face gets a little red, so he takes some benadryl and a leftover steroid pill and calls the ER, demands to speak to the physician on duty, tells me he's driving in and wants me, a nurse, and medication waiting for him on arrival."

# 2

"Staff physician nearly dies but makes a last ditch effort to get to the closest source of epinephrine, barely squeaking out a call to the ED to give them 3 minutes of warning. I coordinate the best possible emergency care with pharmacy staff and nursing staff. On arrival, he is clearly anaphylactic and minutes from death. We rush him into room 1, attach him to a monitor, and slam IM epinephrine into him. The nurse slickly places an IV in seconds and we load him with an H1 blocker, an H2 blocker, and a steroid. He requires a second dose of epi, but then makes a rapid recovery. The patient, his teenager and his wife are intensely grateful for the excellent care received and thank all of the staff multiple times. In fact, they had already thanked the physicians and PAs with a thoughtful Christmas gift a few days before that my kids really liked. It was my pleasure to write the bill off, an option allowed to me as the owner of my business rather than a CMG employee. He will likely continue to refer patients to our ED for years to come and leaves an hour after his impending death was averted with a new-found respect for seasonal allergy shots, the miracle of modern medicine, and the competence of our ED and its staff."

As you can probably tell, it was the same patient. It's all in the presentation/attitude toward what you're doing. If you look for the crappy stuff about your job, you'll find it. There is plenty of it there. But if you look for the little miracles and differences you make that happen all the time, you'll find those too.

Sorry if I just made you feel guilty again, but I wanted to provide another perspective.

No guilt by any of us whatsoever. You have to be "glass half full" and politically correct. You have a brand to protect. That's not necessarily a bad thing.

However, when you're anonymous you have the freedom to curse out the administrator who has never seen a patient, badmouth the gomer who had the nerve to bleed onto your scrubs, and rip consultants a new one for their laziness and self-serving behaviors. That's the beauty of this forum.

However maybe your second account is RustedFox? ;D

 

[GeneralVeers]

You guys way over think this. Most of us are not going to remember the patient interaction if it comes to a suit. Therefore what you write in the record, is all you are going to be able to recall. When the lawyer asks you if you did a 12 point ROS exam and it was negative you say "Yes, otherwise I wouldn't document it". Why would anyone ever be equivocal or say anything else? Anyone who spends time actually doing a BS ROS, or writing down every piddling complaint or +ROS is foolish, and is making their job much harder than it needs to be. Just like never writing down "crushing left sided chest pain" on a patient you are discharging home, don't dig your own grave with too many pertinent positives in the ROS.

 

[TooMuchResearch]

Unless you are getting legit $400/hr, you ain't paid enough.

Seriously.

 

[PlutoBoy]

At work now.
Just had mommy ask for antibiotics "so her daughter wouldn't get sick on Christmas".

Well did you give it to her, you grinch?

 

[RustedFox]

I don't understand the comments regarding getting paid 400/hour.
I realize that I'm complaining; that's the point of the post.
The work isn't hard at all.
I thought I was pretty clear that its the "loss of faith in humanity" and generalized *******ery that's the primary aggravator.

 

[RustedFox]

Well did you give it to her, you grinch?

Hell no. I tried to explain that "that's not how antibiotics work", but she was already too busy on her cellphone by the time I finished my second sentence.

 

[The White Coat Investor]

There's a comedy act in here somewhere. I think your side gig is pretty clear. Kind of Brian Regan meets Louis CK (with his pants on.)

 

[throckmortonDO]

This is seriously my patient list for tonight. 10 hours, 22 patients - not counting MLP supervision/input.

I see alot of these posts saying you should be paid 400$/hr for that - which I'm curious about, because something similar is what I do on a daily basis, I work at several sites - varying acuity, one is solo coverage and you can see >40pts in a 12 hr shift with no midlevel, and the others are similar to the above quote. Honestly I make substantially less <200$ hr - CMG. Not competitive market either - but saturated state. I've thought about looking for another job, my directors are good friends and shield us from corporate bs/pt complaints, but I'm just not sure its worth 100k/yr paycut anymore.

Not to hijack the post - but aside from the SDG partners above with their unicorn jobs - are all CMG jobs basically the same sh** to shovel like I'm currently doing?

 

[RustedFox]

I see alot of these posts saying you should be paid 400$/hr for that - which I'm curious about, because something similar is what I do on a daily basis, I work at several sites - varying acuity, one is solo coverage and you can see >40pts in a 12 hr shift with no midlevel, and the others are similar to the above quote. Honestly I make substantially less <200$ hr - CMG. Not competitive market either - but saturated state. I've thought about looking for another job, my directors are good friends and shield us from corporate bs/pt complaints, but I'm just not sure its worth 100k/yr paycut anymore.

Not to hijack the post - but aside from the SDG partners above with their unicorn jobs - are all CMG jobs basically the same sh** to shovel like I'm currently doing?

I have a job at two different CMG health systems. There's a clear difference between the two. Clear.

 

[iish]

I don't get why so many of you guys do this, complain about it, and don't seriously think about leaving. So many other things in this world to do other than clinical medicine. Most things you would have done with your brain power would have likely made you more money with less annoyance. Switch careers and never look back. It's the solution to all the worlds problems.

Sad thing is most doctors wish they had optionality in their careers, but were so engrossed in becoming doctors that they didn't develop any other skill set. 5 years out of residency and they're yearning for other options, fewer hours, etc. Not just in EM, but even worse in surgery, etc. They'll just never let on that they truly wish they did something else.

Medicine isn't what it was 20 years ago and we're all pure commodities. All while our peers from college that are equally smart but chose other careers are rising in the corporate world, making a name for themselves, and seem to be making as much or more money.

Everyone should develop another real skill that they can employ in this world. Whatever that is. It'll give you a sense of freedom so you don't get run into the ground.

 

[Apollyon]

I don't understand the comments regarding getting paid 400/hour.
I realize that I'm complaining; that's the point of the post.
The work isn't hard at all.
I thought I was pretty clear that its the "loss of faith in humanity" and generalized *******ery that's the primary aggravator.

Because the drain on your spirit is worth it. That was the point.

At my underpaid job, the best thing about it are the patients. They are who buoy me, on ****ty days where staff is dead from the neck up.

 

[GeneralVeers]

"The most rewarding part was when they gave me my money!" - Dr. Nick Riviera

 

[Old Grunt]

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

Pro tip.

 

[Old Grunt]

They claim this is fraud though and that insurance companies often send in "fake patients"

So insurance companies commit fraud to investigate fraud? Those guys are tougher than the FBI! I've literally never heard of that happening. I am not saying it doesn't. I've just never heard of it.

 

[GTP]

So insurance companies commit fraud to investigate fraud? Those guys are tougher than the FBI! I've literally never heard of that happening. I am not saying it doesn't. I've just never heard of it.

Lol idk. Im just a lowly pgy3. But I've heard this more than once

 

[Old Grunt]

Lol idk. Im just a lowly pgy3. But I've heard this more than once

That's weird. In the demonstrably paranoid world that is the practice of medicine in the Western World, I've never heard of this happening. It seems a little hokey. I mean, are these people getting a bunch of CTs a year for fake abdominal pain? A gillion useless lab draws and XRs? Sounds even more awful than the RAC audit process.

 

[WilcoWorld]

Pro tip.

I never heard gonorrhea called "Pro Tip" before. But it actually makes sense now that I think about it.

 

[WilcoWorld]

That's weird. In the demonstrably paranoid world that is the practice of medicine in the Western World, I've never heard of this happening. It seems a little hokey. I mean, are these people getting a bunch of CTs a year for fake abdominal pain? A gillion useless lab draws and XRs? Sounds even more awful than the RAC audit process.

Sounds like a myth to me.

 

[BoardingDoc]

That's weird. In the demonstrably paranoid world that is the practice of medicine in the Western World, I've never heard of this happening. It seems a little hokey. I mean, are these people getting a bunch of CTs a year for fake abdominal pain? A gillion useless lab draws and XRs? Sounds even more awful than the RAC audit process.

If this were a thing (which I think we're all realizing it isn't) and I were tagged by one of these mystery patients for a "fraudulent ROS" my first step isn't to justify why my ROS is fine, it's:

1: Look up the contact info for every critically ill patient that was in the ED that day. Extra attention paid if they were really sick/died.
2: Call those people and mention to them/their family that there were people from the insurance company sending fake patients to the ED that day that I was forced to go see which took up time that I could have spent further caring for them/their dying loved one. "Why yes ma'am, I know exactly which company it was. Let me get their info for you."
3: Go buy popcorn

 

[Vandalia]

Sounds like a myth to me.

Like most myths it has a basis in fact. It is true that there are "mystery shoppers" for primary care practices. That is, a patient goes in and complains of hayfever or the like and the insurance company checks to make sure it wasn't billed as a level-5 or of less concern to them (insurance) they were not prescribed antibiotics. That exists, but it is relatively rare and my educated guess is that it is used when there is additional evidence of problems (fraud).

I would be absolutely shocked if it was used in EM, with the exception of the very unlikely possibility of a very minor FastTrack-type complaint. The risk of iatrogenic injury is too high (CT radiation, procedures, controlled substances) and more importantly the cost to the insurance company would be too great. (With the possible exception that if your institution is fraudulently-billing for every procedure under the sun for patients, then the feds might send in an undercover agent, but I would consider that a "fraudulent scheme" rather than actual medicine.)

So it isn't completely a myth, but it probably is one for EM.

 

[BAM!]

I never heard gonorrhea called "Pro Tip" before. But it actually makes sense now that I think about it.

Nah... that's "bush-league."

 

[Old Grunt]

Charting's only goal is for billing and telling YOUR story.

Anyone who charts exactly what a patient says is lying to themselves. I bet no doctor's chart is like a court reporter. If you truly chart only what the patient says, then you will be the slowest doctor or softest doctor. But you will definitely not be a good doctor.

This is a variation of the best charting advice I got in residency and the way I (try) to approach charting. The chart should make coherent medical sense between the HPI and final diagnosis/disposition.

 

[turkeyjerky]

This is a variation of the best charting advice I got in residency and the way I (try) to approach charting. The chart should make coherent medical sense between the HPI and final diagnosis/disposition.

Although I agree (strongly), I do occasionally take satisfaction in charting ridiculous complaints verbatim. "My pain starts in my chest and then goes up to my ear and then wraps around me down to my left pinky toe. Last time they told me it was a UTI"

 

[PlutoBoy]

So insurance companies commit fraud to investigate fraud? Those guys are tougher than the FBI! I've literally never heard of that happening. I am not saying it doesn't. I've just never heard of it.

I know for a fact that Medicare does it.

 

[WilcoWorld]

I know for a fact that Medicare does it.

Please explain how you know this.

 

[PlutoBoy]

Please explain how you know this.

Because I know of people that have been investigated. I also know people that work in the OIG and they have warned me that they also send agents posing as patients to suspected pill mills (at least in Florida).

 

[southerndoc]

Because I know of people that have been investigated. I also know people that work in the OIG and they have warned me that they also send agents posing as patients to suspected pill mills (at least in Florida).

Wonder to what degree they send patients to the ER? I know they probably do it. Wonder if they go all out for CT's and stuff.

 

[thegenius]

This is seriously my patient list for tonight. 10 hours, 22 patients - not counting MLP supervision/input.

Ready? Go. In no particular order, because I can't get CERNER to sort it like that.

1. Forty-ish female. Cough x 3 months. Won't stop smoking. Nuuu Yawwwk. 2 rounds of antibiotics from dip**** primary nurse practitioner. "Dere's fluid on my lungs, dey say, dawwwk."
No cough on exam at all. Won't shut up despite claims of dyspnea. CXR negative. "What about my Cholesterawwwl, dawwwk? Why didntchu TEST faw daat? What kinda'a dawwktah aaah you'se, dawwwk?" Bye.

2. 24 year old male. I like heroin. My mommy brought me here. She wipes my @ss when I'm done pooping. I still don't have a job. Only poor people wear denim. I have an abscess in my left antecubital. It hurts reaaaal baaad. What do you MEAN you can't ADMIT him for his PROBLEM ?!? Incised/drained. I made sure to wave the kerlex soaked in foul-smelling pus by his nose *inadvertently*. Kthxbye. Please go do your drugs in your rich daddy's friend's home next time. Also; consider employment or overdose; your choice. Overdose might be better, son.

3. 40 year old female. Allergic reaction. Urticarial rash. Took a shower; it went away. But... what WAS it, doc? No way to tell. No rash. Bye.

4. 40 year old male. Fever. Obvious trackmarks on left arm and chest. Tries to tell me that its from a "welding torch and brush". I leaned on him after 45 mintues. "Dude, I'm not a cop. I don't even like cops. What are you using?" - "Heroin, doc. All day, every day." Guy is actually septic; but thanks for trying your luck at the "lets lie to the doc game". Admit.

5. 50 year old male. Nausea/vomiting from seafood buffet... but.... the vomiting made my chronic back pain act up. Only thing that works is Dilaudid. I live in Ohio. Where? Marietta.. no, Fremont.. no, Findlay.... Exam negative. Discharged.

6. 21 year old female. "Autism Spectrum Disorder", which means "I don't want to grow up and take responsibility for anything". Won't speak during exam. Mommy answers all questions. Sore throat. I look in throat. Stone cold normal. Mommy says she's coughing and has fever. No cough, no fever. Won't put down cellphone, frequently "talks" to BB-8 droid plush during exam in beeps and boops. My dad would have slapped me; and he would have been right to do so. Discharged.

7. 2 year old female. Mommy: "She had a fever when she came back from her daddy house!!! She won't eat nuthin'!!!" No fever. No cough. Happily eating popsicle. "Whatchoo MEAN you wont give mah baby an x-ray?!? Is we not important? Black lives MATTER!" CXR ordered. Child has still not coughed, nor displayed fever. Discharged. Will field patient complaint for this one. Thanks for the unnecessary visit and x-ray. Your child hates you.

8. SIGNOUT FROM OFF-GOING DOC: 50 year old female. 4 lumbar surgeries in the past year. Still with low back pain and now "New foot drop and incontinence!!!" We go to do signout at bedside. Patient not in room. ***FLUSSSH!!!*** Patient walks back from bathroom. We both see this. No foot drop. No incontinence (seeing as how she just pee'd). MRI negative. Call to neurosurgery.... "Oh... THIS gal?!" "What is she telling you NOW?" My finger up her bum. Normal tone. Discharged. "Can I have a shot of Dilaudid before I go?" - "No."

9. 84 year old female. Fever/chills, dry cough. Flu positive. "Thank you, young man. Can I please go home now? I don't want to be a burden." Do you want some medicine, grandma? ... - "No, I figure that I'll be just fine. I have Tylenol at home. Thank you. Thank you. Thank you."

10. 23 year old male. Crohn's Disease. Hands me last colonoscopy. Minimal involvement of anything. No belly pain. "Why are you here?" - "I'm here because my naturopath told me to come here for 'IV nutrients'." - No joke... that's actually what he said. Labs all normal. Discharged. *** YOUR NATUROPATH TOLD YOU TO COME HERE FOR IV NUTRIENTS ?!? WHAT... WAS A POULTICE OF HERBS CONTRAINDICATED?!? ***

11. 52 year old female. JUST discharged 3 hours ago with diverticulitis. "I pooped again. There was blood. I didn't know what to do, so I came back." - Did you pick up your cipro/flagyl and the rest of the supportive meds? "No." Discharged.

12. 36 year old male. "I pooped twice today. There was blood. I usually only poop once. I have internal hemorrhoids." Also; I only poop once before I finish playing Final Fantasy III on SNES... by 2pm. I never poop twice, and never by the time I finish that part of the game. Guy is 5-foot-5 by 5-foot-5 by 5-foot-5. Can't breathe with his mouth closed. That's all I need to hear. Rectal negative. Hemoocult negative. Discharged.

13. 3 year old hit head on trampoline at local "trampoline park". Got out phone, worked thru PECARN algorithm with mommy at bedside (Thanks, MDCalc!) Mommy: "But.... aren't you doing to do some TESTING?!" We juuuust did that, mommy. Discharged.

14. Glass coffee tabletop pulled down on 2 year old's feet. Crush injury. X-rays negative. Child can be sent home... with his two parents that smell like weed and are too busy asking for more chips to listen to anything I have to say.

15. 19 year old female. Pelvic pain x 3 months. "Have you seen anyone else about this?" - No. - Review of records reveals 2 visits this month for identical complaints, both with negative workups and CT abd/pelvis or ultrasound. Exam stone cold negative. Whole room smells like weed when I walk in. I order necessary testing. No imaging. I walk back in to review results. Somehow; smell of weed is waaay stronger, dude. "I'm not pregnant?! Thanks." I walk out, head to cafeteria. No french fries? Bummer. Cafeteria gal makes me a sandwich because I *looked hungry*. Thanks, Debbie! I love you, and your face, and howaboutItellyouaboutthetimewhereIwalkedintothecafeteriaandyouwerelike!whoa!!

16. 72 year old female. Fat. Hypertensive. Diabetic. Hyperlipidemic. Smoker. Family history CAD+. Chest pain. Admitted in 20 minutes or less.

The other six don't matter... it was either "nonspecific fall in a demented 90+ year old female" or "slam dunk chest pain r/out ACS".

Single funniest thing I've read on SDN in sometime. I don't know what WCI was thinking about above. I know I've just bumped this thread because it's old.

 

[deleted836128]

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.

Oh I like the part about recent injuries. Thanks

This is seriously my patient list for tonight. 10 hours, 22 patients - not counting MLP supervision/input.

Ready? Go. In no particular order, because I can't get CERNER to sort it like that.

1. Forty-ish female. Cough x 3 months. Won't stop smoking. Nuuu Yawwwk. 2 rounds of antibiotics from dip**** primary nurse practitioner. "Dere's fluid on my lungs, dey say, dawwwk."
No cough on exam at all. Won't shut up despite claims of dyspnea. CXR negative. "What about my Cholesterawwwl, dawwwk? Why didntchu TEST faw daat? What kinda'a dawwktah aaah you'se, dawwwk?" Bye.

2. 24 year old male. I like heroin. My mommy brought me here. She wipes my @ss when I'm done pooping. I still don't have a job. Only poor people wear denim. I have an abscess in my left antecubital. It hurts reaaaal baaad. What do you MEAN you can't ADMIT him for his PROBLEM ?!? Incised/drained. I made sure to wave the kerlex soaked in foul-smelling pus by his nose *inadvertently*. Kthxbye. Please go do your drugs in your rich daddy's friend's home next time. Also; consider employment or overdose; your choice. Overdose might be better, son.

3. 40 year old female. Allergic reaction. Urticarial rash. Took a shower; it went away. But... what WAS it, doc? No way to tell. No rash. Bye.

4. 40 year old male. Fever. Obvious trackmarks on left arm and chest. Tries to tell me that its from a "welding torch and brush". I leaned on him after 45 mintues. "Dude, I'm not a cop. I don't even like cops. What are you using?" - "Heroin, doc. All day, every day." Guy is actually septic; but thanks for trying your luck at the "lets lie to the doc game". Admit.

5. 50 year old male. Nausea/vomiting from seafood buffet... but.... the vomiting made my chronic back pain act up. Only thing that works is Dilaudid. I live in Ohio. Where? Marietta.. no, Fremont.. no, Findlay.... Exam negative. Discharged.

6. 21 year old female. "Autism Spectrum Disorder", which means "I don't want to grow up and take responsibility for anything". Won't speak during exam. Mommy answers all questions. Sore throat. I look in throat. Stone cold normal. Mommy says she's coughing and has fever. No cough, no fever. Won't put down cellphone, frequently "talks" to BB-8 droid plush during exam in beeps and boops. My dad would have slapped me; and he would have been right to do so. Discharged.

7. 2 year old female. Mommy: "She had a fever when she came back from her daddy house!!! She won't eat nuthin'!!!" No fever. No cough. Happily eating popsicle. "Whatchoo MEAN you wont give mah baby an x-ray?!? Is we not important? Black lives MATTER!" CXR ordered. Child has still not coughed, nor displayed fever. Discharged. Will field patient complaint for this one. Thanks for the unnecessary visit and x-ray. Your child hates you.

8. SIGNOUT FROM OFF-GOING DOC: 50 year old female. 4 lumbar surgeries in the past year. Still with low back pain and now "New foot drop and incontinence!!!" We go to do signout at bedside. Patient not in room. ***FLUSSSH!!!*** Patient walks back from bathroom. We both see this. No foot drop. No incontinence (seeing as how she just pee'd). MRI negative. Call to neurosurgery.... "Oh... THIS gal?!" "What is she telling you NOW?" My finger up her bum. Normal tone. Discharged. "Can I have a shot of Dilaudid before I go?" - "No."

9. 84 year old female. Fever/chills, dry cough. Flu positive. "Thank you, young man. Can I please go home now? I don't want to be a burden." Do you want some medicine, grandma? ... - "No, I figure that I'll be just fine. I have Tylenol at home. Thank you. Thank you. Thank you."

10. 23 year old male. Crohn's Disease. Hands me last colonoscopy. Minimal involvement of anything. No belly pain. "Why are you here?" - "I'm here because my naturopath told me to come here for 'IV nutrients'." - No joke... that's actually what he said. Labs all normal. Discharged. *** YOUR NATUROPATH TOLD YOU TO COME HERE FOR IV NUTRIENTS ?!? WHAT... WAS A POULTICE OF HERBS CONTRAINDICATED?!? ***

11. 52 year old female. JUST discharged 3 hours ago with diverticulitis. "I pooped again. There was blood. I didn't know what to do, so I came back." - Did you pick up your cipro/flagyl and the rest of the supportive meds? "No." Discharged.

12. 36 year old male. "I pooped twice today. There was blood. I usually only poop once. I have internal hemorrhoids." Also; I only poop once before I finish playing Final Fantasy III on SNES... by 2pm. I never poop twice, and never by the time I finish that part of the game. Guy is 5-foot-5 by 5-foot-5 by 5-foot-5. Can't breathe with his mouth closed. That's all I need to hear. Rectal negative. Hemoocult negative. Discharged.

13. 3 year old hit head on trampoline at local "trampoline park". Got out phone, worked thru PECARN algorithm with mommy at bedside (Thanks, MDCalc!) Mommy: "But.... aren't you doing to do some TESTING?!" We juuuust did that, mommy. Discharged.

14. Glass coffee tabletop pulled down on 2 year old's feet. Crush injury. X-rays negative. Child can be sent home... with his two parents that smell like weed and are too busy asking for more chips to listen to anything I have to say.

15. 19 year old female. Pelvic pain x 3 months. "Have you seen anyone else about this?" - No. - Review of records reveals 2 visits this month for identical complaints, both with negative workups and CT abd/pelvis or ultrasound. Exam stone cold negative. Whole room smells like weed when I walk in. I order necessary testing. No imaging. I walk back in to review results. Somehow; smell of weed is waaay stronger, dude. "I'm not pregnant?! Thanks." I walk out, head to cafeteria. No french fries? Bummer. Cafeteria gal makes me a sandwich because I *looked hungry*. Thanks, Debbie! I love you, and your face, and howaboutItellyouaboutthetimewhereIwalkedintothecafeteriaandyouwerelike!whoa!!

16. 72 year old female. Fat. Hypertensive. Diabetic. Hyperlipidemic. Smoker. Family history CAD+. Chest pain. Admitted in 20 minutes or less.

The other six don't matter... it was either "nonspecific fall in a demented 90+ year old female" or "slam dunk chest pain r/out ACS".

Hands down THE BEST thing I have read all day. Hahaha - made me laugh so hard! All of this is so true!!!