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Treating The Chart, Not The Patient


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I can only speak from the experience of a patient and not of that as a professional, but does it seem as if doctors, nurses and other health professionals have gotten away from treating the patient in favor of treating the chart or test results. I don't understand how a patient can sit writhing in pain in front of a physician and the doctor can look at the test results and say "well there seems to be nothing wrong." Are the days of "practicing" medicine over for fear of how the patient's medical records will present? What if the time spent charting was spent focused on the patient? In your opinion do today's medical charts benefit the patient?

 

What say you?

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It is a shame that our society has moved to the point, and you will hear this mantra over and over, it isn't what you did or didn't do that counts, its what you chart. But that's the direction that patients and lawyers have pushed things. Documentation is the key, not the outcome. It should be the outcome.

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A patient can sit 'writhing in pain in front of a provider who can look at the test results and say there seems to be nothing wrong' because "somatization" does exists... so does addiction, drug seeking behavior, and axis II-Cluster B/secondary gain issues.

 

Are the days of "practicing" medicine over for fear of how the patient's medical records will present?

No... the database (med record) should be seen as a linear historical document that acurately detail previous complaints, clinical evaluations, work-ups and findings.

 

What if the time spent charting was spent focused on the patient?

Then everywhere the patient went, would have to ask the same questions and perform the same tests because there wouldn't be a thouroughly detailed linear historical document that acurately described previous complaints, clinical evaluations, work-ups and findings.

 

In your opinion do today's medical charts benefit the patient?

Yes because without them I wouldn't know that this patient sitting in front of me, in no acute distress, complaining of chronic Lower back pain, neck pain and stating that she requires oxycontin 80mg po tid with oxycodone 20mg bid for break thru pain has indeed had several extensive spinal surgeries and does indeed have significant musculoskeletal and neurological pathology that was confirmed with imaging/emg by both orthopods and neurologists.

 

So now that I have this info, I am more likely to liberalize my analgesic prescribing to this woman while she is a inpatient at my facility because I know if scrutinized, its defenseable, and that I'm not simply being manipulated for illicit secondary gain.

 

Just my initial thoughts...

 

Contrarian

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It is a shame that our society has moved to the point, and you will hear this mantra over and over, it isn't what you did or didn't do that counts, its what you chart. But that's the direction that patients and lawyers have pushed things. Documentation is the key, not the outcome. It should be the outcome.

this is why I enjoy working overseas. charting is only about the transmission of need to know info to the next provider, not cya charting. you should be able to document an entire pt visit with the really relevant stuff on a 3X5 card....I precepted with an older fp doc who kept a pts entire life hx on a single page. each pt had 1 page in his charting system at the front of a folder. labs, etc were also in the folder but all relevant results were on the 1 page. typical entries were 1 line long: c/c, relevant hpi, vs: cough x 1 week. afebrile, stable vs. nl exam. uri. tessalon #30.

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I don't understand how a patient can sit writhing in pain in front of a physician and the doctor can look at the test results and say "well there seems to be nothing wrong."

 

Sounds extreme and I cannot recall seeing a patient whose pain was not treated b/c test results looked "normal". This sounds more like a scene out of a bad medical TV drama than real life. Malingering is a real entity but that is a process which is ruled in/out.

 

EMR is a huge leap in patient care which makes care better, on the whole, and prevents errors.

We spend equal energies on caring for the patient AND documenting, one doesn't take precedent over the other.

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It sounds like the initial question asked why we can't do these tests along with PE and in the end come up with a Dx. Some patients although in pain may not leave with a Dx. I can say I have given pts pain meds not knowing what is going on but also I can say I really look and if that involves labs/rads + PE then I think I'm doing it right. I do not treat a chart or a lab but the patient. Yes this all ends up in the med record but isn't is supposed to? I guess I just don't see the same thing happening.

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Bottom line is these days liability and lawsuits reign supreme in most clinicians minds. Sad fact but the way healthcare has gone. There are no 100% guarantees in life but yet clinicians are suppose to be right 100% of the time or else... That is why so much detail is spent on charts because we have 30 min to put together and create a chart but lawyers have weeks to comb through and look for things to pick at. In my opinion the only thing good from a chart for clinician purposes is old medical records to help guide current tx. I.E PMH, old lab/radiology results, and pointing out recurrent visits to ED for "toothache," "back pain," or other typical narc seeking behavior.

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