Rookie mistakes in IM

[grendelsdragon]

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You are both right...in a way. It's important to document the RELATIVE physical exam points...that would be a pretty extensive PE for an admitted/new patients and then relevant exam points on a daily basis. Also, one HAS to think about coding and billing...you, the attending, need to teach the residents about this because they weren't born knowing.

Grendelsdragon, you seem to think that the lack of pertinent details on some house staff notes are always due to laziness that you would punish by giving them a "poor evaluation". IMHO, a lot of this is due to house staff and students never having been taught how to do a proper physical exam and find the relevant findings...students and house staff were not born knowing how to hear an S4 or a decrescendo murmur or measure pulsus paradoxus. So if you are one of the "good attendings" who actually teaches this stuff, then good for you. There are many attendings who do not teach much at all about physical diagnosis and I believe this is what you are seeing evidence of in your house staff's notes. Unfortunately, the almighty dollar and so-called "efficiency" (i.e. dotting all the billing-and-coding i's and crossing all the t's so the hospital can bill maximally for each admission, plus discharging patients by 8 or 9a.m.) has become king and patient care and teaching have suffered, IMHO.

Excellent points.

Although I said I would "grade poorly", I have seldom ever done so. The necessity to grade poorly is as much a failure on my part. Our responsibilities as attendings is to clearly outline our expectations at the beginning of any tour of duty. Also, I resist temptations to "card flip", but rather try to do walk rounds with bedside teaching whenever possible.

This is such a great time to be learning medicine. Our diagnostic tests can be used to complement our history and physical exam skills (such as with ECHO and hemodynamic cath data). We just have to resist temptations for these tests to supplant clinical judgement. Physical exam takes practice with validation (like ECHO). A lot is also pattern recognition, which is hard to learn if we adhere to a fixed template of a normal exam.

 

[nope80]

great thread!

 

[jdh71]

great thread!

I don't always understand the billing for the surgical side of things so I don't know how much any of this applies, but for medicine, this thread needs a bit of an update . . . on an H&P you NEED to document 10, yes that is correct, document TEN ROS findings, even if negative. Remember 10 systems when you do your dictations and you won't be getting angry pages from attendings wondering why you are not documenting their H&P correctly. Do you already dislike them so much you want their children to starve? Also, the PE needs 8 systems to be complete for billing purposes, and edema in the lower extremities doesn't count for an extremity exam - it's considered a CV finding.

 

[LukeWhite]

A few billing-specific points since we're on the topic.

--You do need a minimal ROS number for H&Ps. However, the phrase "review of all other systems is negative" is accepted in some states for some insurances. In Indiana, we can continue to use it.

--A follow-up progress note can wholly omit a physical exam and still bill completely. Or it can omit a history/interval change, or even an assessment and plan. If you have two out of three (each of those two with their own quite specific requirements) you are set. It's been my experience that most hospitalists, including myself, will skip the detailed PE unless it's warranted.

--The above does NOT apply to H&Ps. You need a physical exam that hits a certain number of bullet points. These bullet points are precisely delineated and don't correlate well at all with how residents are taught to do their exams.

--The Happy Hospitalist has a lot more on all this for those interested in the everyday considerations and calculations that hospitalists make when thinking about their notes. I've also made up some note templates that I'd be happy to share with any interested.

My thoughts on notes: As a hospitalist I document the bare minimum for my intended level of billing and then add whatever I believe is important to communicate to partners, consultants, nurses, or my tomorrow-self. This usually isn't too much.

As a resident, though, I slaved over my notes (occasionally redoing drafts), making sure that they were the most legible note in the chart, had plenty of white space making them easy to read and copy, and included a detailed explanation of my reasoning. I did this partly because I knew attendings, consultants, etc would spend more time with my note than with me. And also because the note that is the most readable is the one that will be read.

Your influence, and others' estimations of your clinical judgment, will grow in proportion to your notes' legibility and prose. Guaranteed. If you have to cut corners to make that happen, do it on your physical exam.

 

[MedicineDoc]

I agree. It's also very annoying when medicine housestaff write notes like this:
S: No complaints
O: AF AVSS
NKDA
NCAT
Lungs CTAB
RRR NS1S2 No M/G/R
Abdomen soft, nontender
Wound CDI
Ext. No C/C/E
*lab tree*
A/P: blah blah

For the record, there is no such thing as a "regular rate and rhythm". The rhythm can be regular or irregular, but the heart rate is either normal, tachycardic, or bradycardic.

It used to be before billing was based on documentation there wasn't anything written in the chart unless something was going wrong. Documentation of normal physical exam findings in my mind is a documentation billing game. Learning how to be anal retentative is not doing the patient any good or contributing anything to anybody. No wheezes rales rhonci / soft/nt/nd is fine in my opinion if the goal is to get paid. Funny how you IM guys teach your interns to spend their time on superficial sludge. "looks good", "will make the team happy", "sounds better". How about focus on learning to undestand the problem and be good rather than sound slick which comes anyway with time.

 

[LukeWhite]

I'll respectfully differ with part of this, in a matter which is admittedly only opinion. Sounding slick is a CRUCIAL skill to work on, not only for teams and attendings, but for patients.

90% of what you do is obvious, but you've got to sell it. Working on your schtick is especially important in everyday clinical practice if you want to translate your clinical knowledge, which residency will beat into you, into efficacy and patient satisfaction, which it won't. You need scripts, metaphors, clear catch phrases in your notes that convey complex ideas in digestible bullet points for busy consultants. I think this is worth working on.

 

[leodavis]

thanks for all the great advice, guys.

for those of you who've survived intern year (and maybe residency, fellowship and attendingship....):

are there any other rookie mistakes you made or saw made as interns that we should look out for? how did you keep it together in July without spazzing out?

 

[jdh71]

thanks for all the great advice, guys.

for those of you who've survived intern year (and maybe residency, fellowship and attendingship....):

are there any other rookie mistakes you made or saw made as interns that we should look out for? how did you keep it together in July without spazzing out?

You don't.

I think the best approach here is to be zen about it. Accept that it's going to be a train wreck, BUT that you will figure it out anyway. I would recommend keeping a binder (print off or photocopy you daily note) and keep a separate section on each patient you are following. Write "to do's" and other pertinent information of these sheets to keep yourself organized.

You may not like the binder approach by August, but I think it's the approach most people end up preferring so it's what I initially suggest to try.

It's all calibration.