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.