Tips for New Docs?

[da8s0859q]

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Just the facts. Learn billing elements early and document accordingly and properly. Helps maximize attending/group/hospital income, whatever the system is where you are, and gets you into good habits early.

MDMs need not be War and Peace. Tell me what you felt it was, why, and why it wasn't all those other worse things. Include anything important ("shared decision-making" being all the rage, repeat evaluations, any notable ED course turns, so on). Anything inherently risky -- sending home abdominal pain with a 12-24 hour recheck for an appy if that's your culture, whatever else -- needs to be explicitly spelled out and backed up.

Basically, write the MDM that would make you think, "Damn, I'm glad I wrote that" if you had to review it at a deposition one day.

 

[Zebra Hunter]

Just the facts. Learn billing elements early and document accordingly and properly. Helps maximize attending/group/hospital income, whatever the system is where you are, and gets you into good habits early.

MDMs need not be War and Peace. Tell me what you felt it was, why, and why it wasn't all those other worse things. Include anything important ("shared decision-making" being all the rage, repeat evaluations, any notable ED course turns, so on). Anything inherently risky -- sending home abdominal pain with a 12-24 hour recheck for an appy if that's your culture, whatever else -- needs to be explicitly spelled out and backed up.

Basically, write the MDM that would make you think, "Damn, I'm glad I wrote that" if you had to review it at a deposition one day.

Does the bolded portion actually matter medicolegally? Most of the time I get n/v/d patients, I know it's most likely gastroenteritis, but I see no benefit to actually putting that on a chart. Also, why bother stating why it is not "all those other worse things"? If you're sending them home, it's plainly clear that you do not believe it's the worse stuff, and my chart is going to reflect that.

I can't imagine you stating that a child most likely has a viral URI rather than pneumonia based on X,Y, and Z is going to be much more defensible in court than just a well documented HPI, PE, and discharge instructions, and I'd imagine that in many cases it might harm you.

 

[DrZeke]

It's not overrated but you can't expect nuanced, insightful, or generally even accurate responses. If you're taking the history right, Yesses and Nos should comprise about 98% of the words out of the patient's mouth.

Exactly... If I realize open ended is getting me nowhere, I move straight to close ended and fast.


Sent from my iPhone using SDN mobile app

 

[gro2001]

That would be NNH in this case.

Anyone any documentation tips? Pretty anxious about it for some reason.

1) A common issue I see with a lot of interns (and not only interns) notes is writing up very detailed, well written histories and physicals, and then writing up bare bones A/Ps. The priority should be on the medical decision making section. For example:

A: Chest pain.
P:
-CXR
-ECG
-Trop x 2
-DC

...is not sufficient. You should have at least a couple of different diagnoses that you considered and ruled out in your assessment. You don't have to have done tests on them, just documented that you thought about it and decided you were not clinically concerned. For example:

A: Chest pain, not exertional. Not concerned for PE given lack of risk factors and PERC negative. Not concerned for dissection given mild nature, rapid improvement, and overall clinical picture. No signs of Pneumonia. Overall low concern for ACS, but will get troponin x 2 to r/o MI and patient says will follow up with PMD tomorrow. Patient agreeable with plan.
P:
-CXR
-ECG
-Trop x 2
-DC

2) Always add a reassessment exam before discharge. It doesn't have to be a full physical, or anywhere near it. Just a brief note saying:

"Patient now clinically sober, steady on feet, eating turkey sandwich, asking to be discharged"

or

"Abdomen still soft, not tender, not distended, CT negative and discussed with patient, tolerated PO, will DC."

is sufficient. Same applies if the patient is boarding in your ED for a very long time, awaiting hospital admission, or whatever.

3) After those two, the most important piece of documentation, in my opinion, is the discharge instructions to the patient. The premade stuff so many EDs make you print to give to patients is largely useless. The one sentence you write down as the bottom line of what the patient should do after leaving the ER might be useful. Both to the patient and to you, medicolegally. So make sure it is written in a way that will look good in the retrospectroscope and is difficult to misinterpret. These are verbatim some things I've seen interns write as discharge instructions:

"Return to ER PRN."

"Return for NVD."

"RTC 2-4 weeks."

In other words don't use abbreviations, spell out things that seem to be obvious and give specific time courses. If you can, spell out what your findings were in the ED. For example:

"We did not find a cause for your chest pain today. Please follow up with your primary doctor within 2-3 days for re-evaluation and possibly further testing. If your symptoms return, worsen, change, please come back to the ER immediately."

4) It helps to have macros to type out a lot of these things for you. Most EMRs will have some useful shortcuts available, but well hidden. Find some attending who seems somewhat tech savvy and ask him or her how they do it.

 

[gro2001]

Does the bolded portion actually matter medicolegally? Most of the time I get n/v/d patients, I know it's most likely gastroenteritis, but I see no benefit to actually putting that on a chart. Also, why bother stating why it is not "all those other worse things"? If you're sending them home, it's plainly clear that you do not believe it's the worse stuff, and my chart is going to reflect that.

I can't imagine you stating that a child most likely has a viral URI rather than pneumonia based on X,Y, and Z is going to be much more defensible in court than just a well documented HPI, PE, and discharge instructions, and I'd imagine that in many cases it might harm you.

I think it could help. I am no medicolegal expert (most of my knowledge comes from hear say and Greg Henry's books) and I am a very new attending so take whatever I say with a grain of salt. I have however been involved in a couple of criminal cases where (the people who assailed my patients were on trial) and it became important to figure out why I thought or didn't think of particular injuries and general condition of the patients that could change the outcome of the case.

I think it would help most when upon reading the history and physical it's not actually clear what the #1 diagnosis is. Say you have a headache patient. If your history hits so many of classic points that by the time I am done reading it's screaming 'migraine' at me, then going into specifically why you don't think it's meningitis or SAH is not going to add too much. However, if when I read the history I am not sure if it sounds more like tension headache or atypical migraine, or something else, it becomes important to explain why you don't think that something else is something bad. Even if you think it's obvious from your history, it might not be on a second reading 1 year later. You would be surprised how many questions a detailed nitpicking, of even a well written chart and an obvious case, can produce.

If you don't believe me, try this (if your EMR allows you to): go find a couple of random charts you wrote 1 year ago, someone you discharged who is over 50 years old, and imagine you have to defend that chart in court from some adverse event. Is it overwhelmingly obvious to you why you didn't admit that patient or do that extra test?