jmj11 Posted December 19, 2018 Share Posted December 19, 2018 So, this crossed my mind today. I was seeing a patient who is always unkempt and smell foul (BO, urine, possible feces) and in their 20s. They are applying for disability and I believe that they deserve it because of their mental health issues (not headache). They are brought in by their mother and rarely leave their bedroom (agoraphobia). In the old days you would make such objective statements at the patient smells of urine and is unkempt. I think it is relative to their over-all mental state and an important part of the exam. However, since the days of patient portals and reading their own records, this would really piss off (speaking of a urine smell) some patients. Link to comment Share on other sites More sharing options...
Joelseff Posted December 19, 2018 Share Posted December 19, 2018 It depends on how bad they smell... Lol no I always document appearance especially if it is off their baseline I will add something like "pt's clothes are dirty and pt is unkempt today which is not their usual presentation" or something like that.If they always smell I will put "pt smells of..." usually urine or Marijuana but I do have a pt that smells like she sleeps in a barn and has brought animals in with her at visits. She's an eccentric old lady who actually is quite wealthy lol. Had a TAVR and will not take Xarelto because she is convinced it is "made by Nazis."She's fun but not her smell. Sent from my SAMSUNG-SM-G891A using Tapatalk Link to comment Share on other sites More sharing options...
thinkertdm Posted December 19, 2018 Share Posted December 19, 2018 O=objective, facts that we as trained observers document. Don't be bullied by patient opinion. Would avoid subjective statements, unless you know for sure it is x, y, or z. "Malodorous" I like "the rank smell of cigarettes wafted around his body". Don't be bullied. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted December 19, 2018 Share Posted December 19, 2018 Adult pt. “General: Vitals reviewed. Pt in NAD and alert. Pt arrived for afternoon appt in their pajamas.” I typically don’t document aromas though I will note disheveled appearance. Link to comment Share on other sites More sharing options...
thinkertdm Posted December 19, 2018 Share Posted December 19, 2018 It it's pertinent, it goes in, such as where I'm concerned about falls, mental status, etc. I also avoid "smells tantalizing" because I like to keep my job. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted December 20, 2018 Administrator Share Posted December 20, 2018 Somewhat tangentially, one of my pet peeves is a pre-demographic adjective: "So and so is a pleasant 31 YOM" I'm sorry, but how nice they are isn't the very first first thing I want to convey in my note. It'll still show up if appropriate, just later. Link to comment Share on other sites More sharing options...
thinkertdm Posted December 20, 2018 Share Posted December 20, 2018 5 hours ago, rev ronin said: Somewhat tangentially, on of my pet peeves is a pre-demographic adjective: "So and so is a pleasant 31 YOM" I'm sorry, but how nice they are isn't the very first first thing I want to convey in my note. It'll still show up if appropriate, just later. I always thought "pleasant" was code for crusty jerk, thanks for sending him my way. Link to comment Share on other sites More sharing options...
Reality Check 2 Posted December 20, 2018 Share Posted December 20, 2018 I put in their hygiene and appearance. It is an objective finding that supports mental health and psychosocial situation. If I put delightful in a chart, it means the person is really nice and easy to work with. Pleasant means they are cooperating. Agitated, anxious and uncooperative enter my chart often as I see a group of folks with extensive mental health issues. Or dementia "limited historian, aloof, unable to provide information". "patient smells very strongly of cigarette smoke (sub - marijuana)" is very very common in my charts. "patient has inappropriate laughter and appears acutely under the influence of substances" - the contact high was overwhelming. "patient smells strongly of alcohol at 11 am. Patient denies drinking" is also a known thing. Stale booze just sucks for the examiner "limited personal hygiene" --- "moderate grooming" --- "disheveled" --- "work worn clothing and work dirty hands" "pt has odor of urine" "pt has odor of cat urine" - meth labs smell like ammonia and cat urine "pt unable to sit for history due to back pain" "pt pacing and fidgeting" --- "pt rocking back and forth" -- yep, common It is all relevant to the situation and context. I don't care if they can read it. I don't put in things like snarky, mean or dressed like a hooker --- that is inappropriate. I use terms when appropriate such as verbally confrontational or combative, loud, angry, agitated and then all the psych things like tangential, withdrawn, etc. Paint a picture in the chart. It means something. Just my crusty old 2 cents Link to comment Share on other sites More sharing options...
Moderator ventana Posted December 20, 2018 Moderator Share Posted December 20, 2018 "unkempt, strong smell of body odor and urine" yup goes in chart Link to comment Share on other sites More sharing options...
CAdamsPAC Posted December 20, 2018 Share Posted December 20, 2018 Sergeant Joe Friday said all that's needed to be said " just the facts, just the facts". Link to comment Share on other sites More sharing options...
Maureenpac Posted January 1, 2019 Share Posted January 1, 2019 I won’t say that you do it every time, but most. For me it is part of the neuro psych stuff of my note. I work in the er....no one smells right Link to comment Share on other sites More sharing options...
Guest Paula Posted January 7, 2019 Share Posted January 7, 2019 20 year old woman complaining of 12/10 pain to bilateral wrists and neck. During medical interview the patient is noted to be texting furiously with her head in a flexed position. Eye contact was null and void. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 7, 2019 Moderator Share Posted January 7, 2019 "anxious and dramatic"...this pt is wasting my time and yours and will be getting haldol as soon as I can make it happen. "this pt has a strong odor of cannabis and the affect of a chronic daily user(they may be stoned right now)". I put this in a note yesterday Link to comment Share on other sites More sharing options...
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