Wednesday, March 2, 2016

Great physical exams

Seen in a chart:




Thank you, H!

20 comments:

Anonymous said...

I concur!

Anonymous said...

Not sure if that's a patient's vitals or carpentry measurements.

Scrub Ninja said...

97.6, 64, 16, 144/65, 98%

At least this doc included punctuation. Vitals are lot harder to read without it.

Renee said...

i get that three of them are temperature, blood pressure, and O2 sats, but what are the other two? 64 might be age? What's the 16? <<< totally not a medical person but I play one on TV

Kassy said...

If the visit was predominantly counseling than little to no physical exam is necessary. In reality, this is true for many visits but since getting paid for doing what is needed isn't really possible, docs document perfunctory physicals all the time.
So kudos to this doctor for not documenting unnecessary stuff(if that is what happened, don't have the rest of the note to be able to make any determination)

Anonymous said...

Temperature: 97.6; Heart Rate: 62; Respirations: 16; Blood Pressure: 144/65. Got it. What is 980?

Anonymous said...

Lottery numbers, like in fortune cookies?

Anonymous said...

Which one is the patient's salary?

Yoko Drāno said...

"Body an 8, face a 3."

Anonymous said...

last number is (likely room air) Saturation ( %), as no supplemental o2 is documented. However, this habit of limited (and substandard)) information is why the chart police (billing, coding twins) started the dreaded capture form bullets, then EMR.... with has more useless data ... but that is another rant

Orli said...

As a student nurse, if this was my note, I'd get remediated for incomplete assessment, incomplete charting, unsafe practice, not to mention poor handwriting. This is BS and it's half the reason I spend hours looking over every chart I deal with just to make sure I'm reading everything correctly--that "62" for heart rate with a comma could just as easily be a "64" without, and while in this case it's not particularly problematic, what if it was a lab value? a medication dose? Those are real problems that can cause real issues.

Anonymous said...

For privacy protection, all patient information must now be illegible and incomprehensible in order to be HIPAA-compliant.

Pam said...

@Anon 2:45

That made me laugh out loud. Thankfully I wasn't drinking anything at the time.

Number Six said...

I am not a number, I am a free man!

Deborah Brett said...

In the interests of patient privacy, all chart notations will now be made in sanskrit.

Packer said...

Did she live?

NurseBear said...

64 - Heart rate
16 - Respiratory rate. Everyone, unless dead or hyperventilating, must have a respiratory rate of 16. It's the law.

Anonymous said...

Guess someone didn't have a piece of scrap paper, or the back of his hand was already covered.

Anonymous said...

Strength, intelligence, wisdom, dexterity, constitution, charisma.

Laura said...

I needed that smile!

 
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