I have a new Nurse Practitioner student precepting with me for the next few months, so I’m once again plunged into the world of the learner. This one’s pretty sharp, but there are still some things we need to work on, as I was reminded when I saw her first effort at documenting a normal physical exam.
Medical charting has always been a balancing act between too little and too much. Family docs as recently as the 70s and possibly 80s could document an entire visit on one line. You don’t have to go back very far, charts from family docs from the 70s and 80s, to find charts with the entire exam documented “WNL” (“Within Normal Limits”; though some claim it means “We Never Looked.”) Clearly that’s too little.
Here’s a student version of what is essentially a normal exam:
TM pearly gray, auditory canals non-inflamed; auditory canals clear, no cerumen
Nares patent, tubinates pink, clear nasal discharge
Oral mucosa and palate pink, good dentition, tonsils pink, no exudate seen
Neck supple, no palpable cervical or supraclavicular nodes, trachea midline, non-palpable thyroid
Lungs CTA bilaterally, no wheezing, crackles
HRR, normal S1/S2, no murmurs, no gallops
Abdomen with +BS in all four quadrants, liver and spleen non-palpable
That’s just half of it. To my eye, it’s a little too much. Here’s how I would document the same exam:
HENT: pearly TMs, throat pink, nose pink/clear
NECK: supple, no nodes
CHEST: lungs clear, cor reg, no m/g
ABD: NABS, soft, non-tender, no mass/megaly
So how do you determine how much is “just right”? Medical documentation has to serve many purposes, including legal, clinical, and payment justification. You must have enough to convince the lawyers that anything that may have gone wrong wasn’t your fault, and, sadly, you need enough to prove you deserve to be paid for the work you did. But as a practical matter, the main day-to-day function of medical documentation is to describe what happened, both to yourself and to any other doctors who may take care of the patient; mostly yourself.
The idea is to keep the “normal” documentation brief and clear enough so that ABNORMALS STAND OUT. Some EMR templates automatically BOLD abnormal findings, mainly by having the normal exam in boilerplate and allowing the physician to free type abnormal findings. By documenting normal exams the same way every time, my eye can quickly pick out abnormalities; a heart murmur, a rash, ankle swelling, bulging red tympanic membranes, etc. But the only way it works is by keeping the normal exam as concise as possible. Not too much, but not too little; just right.