If you grow apples the whole world is the apple orchard. From my perspective if there is a murmur of questionable pathology you document it and get a freaking echocardiogram. If there is JVD you document the extent in addition to pulmonary findings and move on . The real meat of the note should be under assessment and plan. Actual discussion of the patients condition should occur between those involved in patient care. Ticky Tack reporting of findings on daily notes is irrelevent if you are aware of the patients condition and proceed in the correct manor. Nobody cares except for those who seek to separate themselves out from others based on factors other than quality of patient care. Reimbursement based on the number of findings is exactly my point. The attending signs under with agree with above finding and plan and is reimbursed based on that hence attendings request documentin a certain number of findings on resident notes. Hence NCAT, PERRL, no R/R/W, no C/C/E, RRR, EOMI, C/D/I, CTA-B.
You are very passionate about house officers' not documenting relevant physical exam findings, but rather to use "NCAT, PERRL, no R/R/W, no C/C/E, RRR, EOMI, C/D/I, CTA-B". I simply disagree with you, and I would grade my residents and medical students poorly if they took the same stance.
I have yet to meet a single cardiology admission where NCAT is relevant. Additionally, aside from the very first assessment, PERRL and EOMI also fail to be informative (unless the patient might have had a post-cath CVA).
Let me illustrate my point with a few examples:
-If a patient presents with acute symptoms of angina, wouldn't it be appropriate to document that he had a weak carotid upstroke, normal S1, muffled A2 component of S2, with a late-peaking crescendo systolic ejection murmur? I would not wait until the ECHO to confirm obvious physical findings before warning other physicians about avoiding nitrogylcerin (which could be fatal).
-Let's take for example a patient who had presented with acute cor pulmonale from a massive pulmonary embolism. How would you monitor improvement after having given thrombolytics? I would argue that along with improvement of dyspnea, you would also monitor tachycardia, oxygen saturation, resolution of RV heave, and normalization of the P2 component of S2 are reassuring findings worthy of documentation. I do not need waste taxpayer's money to repeat an ECHO.
-How's about run of the mill biventricular heart failure? I would like to see day-to-day improvement in JVP (admitted with 15 cm H2O and Kussmaul's, then prior to discharge down to 7 cm with normal waveforms), daily weight, MR murmur, augmented P2, S3 gallop, peripheral edema, etc.
-Or perhaps a woman with hypotension, JVP up to the mandible, clear lungs, and paridoxical pulse? If she was crashing, I would gather that you would be busy writing "RRR, no M/G/R" instead of performing the life-saving pericardiocentesis.
The exercise of putting together appropriate physical findings along with the clinical presentation not only improves learning, but also improves patient care, saves lives, and also saves healthcare dollars. As for your position that only the assessment and plan counts, an assessment is only as good as it's supportive points.
I do document agreement with resident notes, but all attendings in my division summarize and document their own RELEVENT physical finidngs in their notes, irrespective of the house officer's note. Simply depending upon "agree with above" is lazy and irresponsible.
There is nothing you can possibly say that would change my practice, and I will penalize any medical student, house officer, or fellow who practices according to your style. Period.
