Weird chart notes

[DrMikeP]

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Every now and then I run across some weird phrasing or just unnecessary charting. For example, in the chart I am currently reviewing, it ends with

"Appropriate pleasantries exchanged."

If you don't document this, am I to assume you exchanged inappropriate pleasantries? Anyone else have some good ones?

*please remember not to include any PHI*

Have you ever dictated charting? Often dictations are the best. I've seen some hilarious comments, especially after someone has pulled 4 days of 16hr shifts. Sometimes you will see something typed with "delete last sentence" typed out and the transcriptionist is new so types verbatim.

"motorcyclist vs tree, apparently tree won," "incredibly well endowed young female," " patient talked nonstop until I told her to shut up," "unfortunate young man shot in groin, by I guess she's now his exgirlfriend," "patient killed himself but doesn't know it yet" (overdose initially survived by destroyed liver).

 

[WisNeuro]

I don't personally dictate, I type fairly fast and my reports are fairly templated, so I think it'd just take me longer. But, there are some providers here who clearly dictate with dragon and apparently never proofread before posting.

 

[DrMikeP]

I don't personally dictate, I type fairly fast and my reports are fairly templated, so I think it'd just take me longer. But, there are some providers here who clearly dictate with dragon and apparently never proofread before posting.

I make all of my students/interns dictate at least one report and we listen to them over lunch for fun, but I also use very brief templated style reports just to keep my life easier.

 

[Therapist4Chnge]

People who dictate definitely have some of the best ones. There are some "Dragonisms" that pop up with each version. I don't dictate anymore (strongly encouraged at prior places), as typing is easier for me now for most notes.

 

[bmedclinic]

I wanted to add that I've been on this forum for over 8 years and this is by far my favorite thread.

 

[ClinicalABA]

I don't personally dictate, I type fairly fast and my reports are fairly templated, so I think it'd just take me longer. But, there are some providers here who clearly dictate with dragon and apparently never proofread before posting.

I learned to proofread when using Dragon after coming across the line "is overly focused on climbing on cheerleaders." This was in reference to a 2 year old suspected of ASD who focused on "chairs" and "ladders."

 

[WisNeuro]

I learned to proofread when using Dragon after coming across the line "is overly focused on climbing on cheerleaders." This was in reference to a 2 year old suspected of ASD who focused on "chairs" and "ladders."

Not chutes?

 

[ClinicalABA]

Not chutes?

Nope- climbing on actual chairs and ladders.

 

[WisNeuro]

I assumed as such, just throwing a corny joke out there 🙂

 

[smalltownpsych]

Every time I play chutes and ladders with the kids, they always cheat!

 

[Therapist4Chnge]

Every time I play chutes and ladders with the kids, they always cheat!

Don't worry…there is always Monopoly and Scrabble. A Monopoly loss….is a deep and dark loss (to paraphrase Louis CK).

 

[smalltownpsych]

Don't worry…there is always Monopoly and Scrabble. A Monopoly loss….is a deep and dark loss (to paraphrase Louis CK).

On the other hand, I crush the 10 to 12 year olds at chess. "Ha! That's what you get for not having a fully-developed frontal cortex! I pwned u!"

 

[ClinicalABA]

Every time I play chutes and ladders with the kids, they always cheat!

Every time I play, I always cheat so they'll win and we can get on with our lives. Even the very young kids learn quickly to add some strategy (e.g. Cheating) to pure games of chance like that one and Candy Land. Heck- I'd be disappointed in my own kids if they didn't cheat!

 

[smalltownpsych]

Every time I play, I always cheat so they'll win and we can get on with our lives. Even the very young kids learn quickly to add some strategy (e.g. Cheating) to pure games of chance like that one and Candy Land. Heck- I'd be disappointed in my own kids if they didn't cheat!

Yep. Definitely a developmental stage they go through. I love it when they sneakily stack the deck like I don't notice. 😀 It is also funny when you see the 5 or 6 year old who thinks it is only fun to always win and the 8 or 9 year old sibling who understands rules and gets so mad when little bro or sis keeps cheating. Now when the psychologist gets frustrated because the little kid hasn't reached that developmental phase, then you have to wonder about the psychologist. 😛
It might seem silly but I have actually seen therapists who seem to think that 5 years olds should have the same ability to reason and internalized morality as an adult. I just wish more adults had internalized a belief that rules are important to follow. I don't know what this has to do with weird chart notes other than to say that some of my chart notes, for kids that is, could read about like the last few posts.

 

[Grenth]

Yep. Definitely a developmental stage they go through. I love it when they sneakily stack the deck like I don't notice. 😀 It is also funny when you see the 5 or 6 year old who thinks it is only fun to always win and the 8 or 9 year old sibling who understands rules and gets so mad when little bro or sis keeps cheating. Now when the psychologist gets frustrated because the little kid hasn't reached that developmental phase, then you have to wonder about the psychologist. 😛
It might seem silly but I have actually seen therapists who seem to think that 5 years olds should have the same ability to reason and internalized morality as an adult. I just wish more adults had internalized a belief that rules are important to follow. I don't know what this has to do with weird chart notes other than to say that some of my chart notes, for kids that is, could read about like the last few posts.

Off thread but related to your comment I actually had a five year old kid I saw during my internship for an unrelated to cheating issue whose mom asked me if I could also address the child's poor sportsmanship and cheating at games. I explained developmental stages to her and that the child's behavior was not abnormal, but the funniest thing was that I never observed the cheating and the child was a gracious winner who beat me at everything we played, Chutes and Ladders, Candy Land, Memory, even this psychodynamic board game my supervisor dredged up called The Talking, Feeling, and Doing Game. I was so soundly trounced by this kid every week it was hard on my sense of self-worth related to children's games mastery 😀

 

[temppsych123]

Off thread but related to your comment I actually had a five year old kid I saw during my internship for an unrelated to cheating issue whose mom asked me if I could also address the child's poor sportsmanship and cheating at games. I explained developmental stages to her and that the child's behavior was not abnormal, but the funniest thing was that I never observed the cheating and the child was a gracious winner who beat me at everything we played, Chutes and Ladders, Candy Land, Memory, even this psychodynamic board game my supervisor dredged up called The Talking, Feeling, and Doing Game. I was so soundly trounced by this kid every week it was hard on my sense of self-worth related to children's games mastery 😀

Or maybe that kid was just really good at cheating 😉