Is this standard, or podiatrist-speak for "PITA"?

[dgm]

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Hey guys, I assume that unlike me, most of you have seen patients' records before. I picked up a copy of my records from my former podiatrist's office today, and while I am impressed at how detailed they are, I came away with the impression that he must be glad I don't go there anymore. First, every visit says "Alert, talkative female". It also says things like "___ was discussed in detail", "at length", or sometimes even "in great detail". Just curious - is this fairly normal, or code for "Pain in the ..."? I always felt like we had a friendly relationship, but maybe I was wrong and he was just silently wishing I would just STFU already!

 

[g squared 23]

From what I have heard, this is more a tactic to document thoroughly and for docs to cover their a** in the event they get sued.

For instance, say you present with plantar fasciitis and are tired of dealing with the pain and want it corrected surgically. Most insurance companies want documentation that conservative treatment was at least tried and might not reimburse a doc who goes straight to the knife. By documenting that you were informed "in great detail" of the conservative options, it implies that the doc in no way was acting unethically when selecting a surgical solution (that happens to pay better) to the problem. Or if the surgery has complications, it would help defend against your allegations that the doctor "pushed you into the surgical route" as you were "well informed" of other options that carried fewer risks.

I think the addition of phrases like "was discussed in detail" or "at great length" are not a reflection on you the patient (unless they thought you seemed one likely to litigate), but more the effect of the doctor previously facing a lawsuit and/or covering themselves in the future should one be brought against them.

I also would assume that this type of documentation isn't unique to podiatry but common among others who do elective procedures and surgery.

 

[g squared 23]

"Alert, talkative female"... but maybe I was wrong and he was just silently wishing I would just STFU already!

Btw, just how "alert and talkative" are you anyway?

 

[PMSIII]

Hey guys, I assume that unlike me, most of you have seen patients' records before. I picked up a copy of my records from my former podiatrist's office today, and while I am impressed at how detailed they are, I came away with the impression that he must be glad I don't go there anymore. First, every visit says "Alert, talkative female". It also says things like "___ was discussed in detail", "at length", or sometimes even "in great detail". Just curious - is this fairly normal, or code for "Pain in the ..."? I always felt like we had a friendly relationship, but maybe I was wrong and he was just silently wishing I would just STFU already!

I wouldn't read too much into it. Most physicians and healthcare providers nowadays have to document patient encounters in detail not just for a medical legal point of view but for good documentation and medicare/health insurance purposes i.e. reimbursement. For the most part though, having legible and excellent documentation goes hand in hand with quality patient care - it demonstrates the thorough work-up involved and allows for the physician to transfer records to his/her colleagues (if needed) with ease in order to maintain quality care. You will see that with progress notes, operative reports, consultations, and discharge summaries. This is becoming more and more prominent and standardized in the medical culture in general.

 

[PADPM]

I have absolutely no idea how you would interpret your doctor's excellent documentation for anything else BUT excellent documentation. Just because your doctor describes his/her conversations with you by utilizing terms such as "in detail", "at length", etc., by no means indicates that you are an annoyance.

Your doctor's notes parallel mine and are hopefully an accurate representation of your encounters in his/her office. Don't look for or probe for problems where none exist.

People that DO that on a regular basis end up on a psychiatrist couch.

 

[dgm]

LOL - thanks guys! PADPM, usually when I use the phrase "at length", what I mean is "for an annoyingly long time". 🙂 So that, combined with not knowing whether it's normal to note that a patient is "talkative", just made me wonder. I'm really happy with his documentation though, I've never seen anything so thorough and it is really helpful for filling in the details I'd forgotten.

 

[PADPM]

Well fortunately, with the exception of some species of birds, you won't EVER have to chart that any of your patients are "talkative"!

 

[Feli]

Maybe just charting justification for billing an E/M code based on time length of the visit.

 

[podpal]

Maybe just charting justification for billing an E/M code based on time length of the visit.

This is a very likely reason. Pods get audited by insurance companies a LOT! That you were talkative is good; the patient may understand directions better, as opposed to a pt who is less responsive, flat affect, etc.. For billing purposes documenting that there is some level of patient education is very significant. Good charting also meets requirements of the malpractice insurance companies, and helps keep coverage if something should happen where we need their services.