Tuesday, May 19, 2015

Brevity

Seen in a hospital chart. This was the entire physical exam performed by a neurosurgeon:


"Wait, he left out cyanotic."
For non-medical readers: NAD = "No apparent distress."




Here's another thorough note, this time by an internist:



"Pregnant or non-pregnant. Are there any other human health conditions?"




For all these years, I thought the neurological exam consisted of checking multiple subsystems covering cognition, Cranial Nerves, strength, coordination, sensation, reflexes... and other stuff. Apparently I was wrong, as this hospitalist's entire neuro exam shows:


at

13 comments:

  1. BrianMay 19, 2015 at 5:06 AM

    We've got one doc in my ED who occasionally generates documentation like that. He doesn't like the computer charting, and if there's ever any slightest problem, he never bothers figuring it out or trying again. He throws up his hands (literally) and just saves whatever fragments he already entered.

    One time last year the dictation software quit in the middle of a sentence, so this was his whole note:

    "The patient is a fit and well-nourished seven."

    ReplyDelete
  2. AnonymousMay 19, 2015 at 5:55 AM

    NAD = "not actually done"

    ReplyDelete
  3. RehabNurseMay 19, 2015 at 7:22 AM

    Yes, why do a cranial nerve check, most of those are overrated? He/she will guess that you have a spinal cord injury and an amputation (without even checking).

    No wonder our patients get frustrated going to some of these specialists.

    ReplyDelete
  4. Dr. ZMay 19, 2015 at 8:38 AM

    As a veterinary radiologist, I get even more annoyed when the history documents a complete exam, sometimes even specifying that the neuroanatomic localization is a "T3 to L3 myelopathy," then the images I receive are T9 through the sacrum.

    ReplyDelete
  5. PackerMay 19, 2015 at 9:46 AM

    That is why the Docs get paid the big bucks. Mega, giga , dare I say tetra bucks.

    ReplyDelete
  6. bobbieMay 19, 2015 at 10:27 AM

    Wouldn't a lawyer have fun with that?!?!

    ReplyDelete
  7. brentMay 19, 2015 at 10:39 AM

    nice to see folks using these over priced EMR systems to their full potential.

    ReplyDelete
  8. staceyMay 19, 2015 at 11:21 AM

    "meaningful use"

    hehe

    ReplyDelete
  9. AnonymousMay 19, 2015 at 12:28 PM

    Actually, may be a better note than the usual dribble that gets cut and pasted in EMRs. You get 4 page notes that have one line of useful information, if you can find it.

    ReplyDelete
  10. AnonymousMay 19, 2015 at 12:51 PM

    I'll take a maybe hard to read but meaningful note any day.

    ReplyDelete
  11. KassyMay 19, 2015 at 4:01 PM

    I'd much rather have one line that the doctor actually thought relevant than 4 pages of EMR vomit.

    ReplyDelete
  12. AnonymousMay 20, 2015 at 8:58 PM

    Huh, when I put NAD in a histopathology report, it means No Abnormalities Discovered. Unless I'm looking at a biopsy (which I rarely do) I take it as read that the patient is not in apparent distress, because the patient is dead.
    Then there's NSAD which means just the usual boring background lesions, y'know, No Significant Abnormalities Discovered.

    ReplyDelete
  13. AnonymousMay 20, 2015 at 9:49 PM

    'Nad, go fish, he doesn't fit one of the four cardinal indicators; there's no reason for follow-up. Tell him to pick up his bedroll and send him on his way.

    ReplyDelete

So wadda you think?