The only thing I can think of is that is a trifecta - in the wrong place, has a missing comma and is bad English. One possible interpretation, and there is certainly more than one, might be "Has not been tested for HIV, has declined testing". And who carries the can for taking decisions on the basis of that case note entry? Back in the day, when I took the ECFMG exam and later the VQE, I had to take and pass tests of my ability to comprehend the English language. Perhaps a test of the ability to communicate in English ought to be incorporated in the USMLE...
My frustrations with medical documentation are many.
I am getting so sick of reading the chart-spam that EMR checkboxes and fill-in-the-blank fields provide, like this.
Another thing, almost as bad, is stuff entered by old doctors who can't type, and are under enough time pressure to not go back to fix their typos. So you have a "sentence" that is like six abbreviations, most of them nonstandard, and one spelled-out word with a typo in it.
And then there is any admission note written after 0300, which is probably a pack of lies and guesses that will make you look like an idiot if you rely on any aspect of it the next morning. :/
I think it is gibberish for "A history of not being tested for HIV is a contraindication," or in English, "Do not give this treatment to someone who has not been tested for HIV." But that implies it's in the wrong place on the form, out of context.
The only thing I can think of is that is a trifecta - in the wrong place, has a missing comma and is bad English. One possible interpretation, and there is certainly more than one, might be "Has not been tested for HIV, has declined testing". And who carries the can for taking decisions on the basis of that case note entry? Back in the day, when I took the ECFMG exam and later the VQE, I had to take and pass tests of my ability to comprehend the English language. Perhaps a test of the ability to communicate in English ought to be incorporated in the USMLE...
ReplyDeleteMy frustrations with medical documentation are many.
ReplyDeleteI am getting so sick of reading the chart-spam that EMR checkboxes and fill-in-the-blank fields provide, like this.
Another thing, almost as bad, is stuff entered by old doctors who can't type, and are under enough time pressure to not go back to fix their typos. So you have a "sentence" that is like six abbreviations, most of them nonstandard, and one spelled-out word with a typo in it.
And then there is any admission note written after 0300, which is probably a pack of lies and guesses that will make you look like an idiot if you rely on any aspect of it the next morning. :/
Gees, what is so hard Google it already!
ReplyDeleteI think it is gibberish for "A history of not being tested for HIV is a contraindication," or in English, "Do not give this treatment to someone who has not been tested for HIV." But that implies it's in the wrong place on the form, out of context.
ReplyDeleteI took it to mean the patient has not been tested for HIV because it is contraindicated for them for some reason not given.
ReplyDeleteIt's time to be tested!?
ReplyDelete