Sounds legit. I mean - what's the preferred alternative?
Interim history: Patient reports normal appetite, no cough/sneeze/vomit/diarrhea, normal urination, normal exercise tolerance, no new-onset clinical signs of illness or other abnormalities since last visit. Patient reports mostly staying at home and watching Netflix due to Covid.
Physical exam: EENT WNL, LN WNL, H/L WNL w/no murmur or arrhythmia ausculted, normal peripheral pulse pressures, mm p/m, CRT <2 sec; belly soft/nonpainful; digital rectal exam nonremarkable; normal gait and mentation; no dermatological abnormalities seen on exposed skin.
Plan: patient to monitor self for signs of illness including but not limited to fever, rash, inappetance, vomiting, nausea, diarrhea, constipation, pruritus, anxiety, sense of impending doom, burning while urinating, dysuria, stranguria, pollakiuria, erectile dysfunction, insomnia, anosmia, cough, tachypnea, dyspnea, syncope, or seizure. If any such signs develop, patient to seek care via call our office or present to ER. If no such signs develop, patient to follow up here with another exam in three months.
My last two doctors sat across the room(pre-COVID)and asked questions, as they typed into a laptop. We could have phoned it in. I suspect they weren't typing my answers, just catching up on their email. Or ordering lunch. One of the criteria if I start looking again is a doc who is computer illiterate.
And this is exactly why I pooh-pooh my dr claiming a need to see me every three months!
ReplyDeleteSounds legit. I mean - what's the preferred alternative?
ReplyDeleteInterim history: Patient reports normal appetite, no cough/sneeze/vomit/diarrhea, normal urination, normal exercise tolerance, no new-onset clinical signs of illness or other abnormalities since last visit. Patient reports mostly staying at home and watching Netflix due to Covid.
Physical exam: EENT WNL, LN WNL, H/L WNL w/no murmur or arrhythmia ausculted, normal peripheral pulse pressures, mm p/m, CRT <2 sec; belly soft/nonpainful; digital rectal exam nonremarkable; normal gait and mentation; no dermatological abnormalities seen on exposed skin.
Plan: patient to monitor self for signs of illness including but not limited to fever, rash, inappetance, vomiting, nausea, diarrhea, constipation, pruritus, anxiety, sense of impending doom, burning while urinating, dysuria, stranguria, pollakiuria, erectile dysfunction, insomnia, anosmia, cough, tachypnea, dyspnea, syncope, or seizure. If any such signs develop, patient to seek care via call our office or present to ER. If no such signs develop, patient to follow up here with another exam in three months.
Everything looked good compared to what?
ReplyDeletePatient is 95, 3 months is a goal
ReplyDeleteMy last two doctors sat across the room(pre-COVID)and asked questions, as they typed into a laptop. We could have phoned it in. I suspect they weren't typing my answers, just catching up on their email. Or ordering lunch. One of the criteria if I start looking again is a doc who is computer illiterate.
ReplyDeleteIt is decidedly so.
ReplyDeleteSigns point to yes.
Reply hazy, try again.
The jinotega is behind the 8 ball
ReplyDeleteBetter than 95% of the template-generated EMR notes I read.
ReplyDeleteIf you combine this with the problem list in the chart, which I'm going to guess is similarly brief and to the point, you've got all you need to know.