Posted by: notdeaddinosaur | May 7, 2014

All Physical Exams are Not Created Equal

Once again, I am in receipt of a letter from a specialist (a surgical subspecialty, of course) that has me alternately shaking my head in disbelief and trembling with fury.

The letter was clearly crafted with electronic medical record software to support billing as high a level office visit as possible. In addition to a complete specialty-specific organ system examination, a “Multi-System Physical Examination” was also documented:

  • Constitutional: well-nourished, no physical deformities, normally developed, good grooming
  • Neck: neck symmetrical, not swollen, normal tracheal position
  • Respiratory: no labored breathing, no use of accessory muscles
  • Cardiovascular: normal temperature, normal extremity pulses, no swelling, no varicosities
  • Lymphatic: no enlargement of neck, axillae, groin
  • Skin: no paleness, no jaundice, no cyanosis, no lesion, no ulcer, no rash
  • Neurologic/Psychiatric: oriented to time, oriented to place, oriented to person, no depression, no anxiety, no agitation
  • Gastrointestinal: no mass, no tenderness, no rigidity, non-obese abdomen
  • Eyes: Normal conjunctivae, normal eyelids
  • Ears, Nose, Mouth, and Throat: left ear no scars, no lesions, no masses, right ear no scars, no lesions, no masses, nose no scars, no lesions, no masses, normal hearing, normal lips
  • Musculoskeletal: normal gait and station of head and neck [whatever the hell that means]

This is verbatim, by the way.

If I saw this from a medical student, it would be a big fat fail. Oh, there are plenty of bullet points, and they’re arranged in enough lines to pass the billing clerk’s checklist. But it basically says next to nothing.

The really interesting thing about this writeup is that although the patient is being seen for an unrelated problem, it completely fails to convey that she is actually a heart-lung transplant candidate. This surgeon probably doesn’t even own a stethoscope anymore, because anywhere you’d care to put one on this patient’s chest reveals findings that are anything but normal. She’s missing a lobe of one lung, and her heart swishes and hums more than it lubs and dubs. Frankly, I doubt the specialist even realized there was anything wrong.

More proof, as if it were needed, that EMRs document for billing instead of medical care.


Responses

  1. Reblogged this on Ann Friedmann MD and commented:
    This speaks to why the Electronic Medical Record will NEVER save money as it was hoped to.I am sure Doctor Dinosaur is absolutely correct in his assessment.

  2. WTF!

    >

  3. That must be the same idiot who found the tumor on my left adrenal gland while I was being treated for hypokalemia and said he saw nothing wrong. Thanks to him I have enjoyed (NOT!) the Cushing’s syndrome for 9 more years. I can see why you are trembling with fury.

  4. Unbelievable and yet so believable!

  5. Reblogged this on Underwriting Solutions LLC and commented:
    Amen Dr. Dino.

  6. And even when the exam does make sense you know jolly well the orthopedic (or whoever) never listened to their heart!

  7. Amen, sister!

    This is akin to the “looks good from door” of the orthopaedics patients.


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