"It's all in my chart."

[RedPeony]

Curious how others deal with it when they are asking a pt basic history questions and the patient says "look at my chart, it's all in my chart" or "I just told the other doctor that, just read my chart." I can understand not remembering med doses or other detailed info, but pts seem to believe that the EMR can easily tell us everything we need to know.

I had a pt today who essentially wanted me to construct a whole H&P via chart review, meh. I just ended up saying "I'm sorry, but you have hundreds of notes in your chart and often the information in your chart is incorrect so I prefer to hear it from you. If there's something you don't remember, that's okay and we can use the chart to fill in some details."

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[smq123]

Curious how others deal with it when they are asking a pt basic history questions and the patient says "look at my chart, it's all in my chart" or "I just told the other doctor that, just read my chart." I can understand not remembering med doses or other detailed info, but pts seem to believe that the EMR can easily tell us everything we need to know.

I had a pt today who essentially wanted me to construct a whole H&P via chart review, meh. I just ended up saying "I'm sorry, but you have hundreds of notes in your chart and often the information in your chart is incorrect so I prefer to hear it from you. If there's something you don't remember, that's okay and we can use the chart to fill in some details."

Even better when they're a brand new patient, but insist that all their information is "in their chart." Then they look truly shocked to hear that not all clinics communicate directly with each other, all the time.

Even BETTER is when they're a brand new patient from a whole other country. No, we don't have immediate access to your paper chart in Bangladesh.

 

[Pes anserine]

Curious how others deal with it when they are asking a pt basic history questions and the patient says "look at my chart, it's all in my chart" or "I just told the other doctor that, just read my chart." I can understand not remembering med doses or other detailed info, but pts seem to believe that the EMR can easily tell us everything we need to know.

I had a pt today who essentially wanted me to construct a whole H&P via chart review, meh. I just ended up saying "I'm sorry, but you have hundreds of notes in your chart and often the information in your chart is incorrect so I prefer to hear it from you. If there's something you don't remember, that's okay and we can use the chart to fill in some details."

We get that all the time. I obviously do a thorough chart review prior to seeing my patients and I frequently start with open ended - how are things going since last time you were here? Patient blahs about something, then I say something like, it is my understanding that this happened, or this medication changed, etc. That typically gives the patient peace of mind that I know "the chart" - I even had a patient tell me this week how awsome he felt I was because I knew so much about him and had looked over his records before seeing him and he gushed about me to the attending. At other times when I ask something and the patient continues to insist it's "in their chart" I say, well every time you come to the doctor's office, we are going to ask certain things, regardless of what's in your chart. We do this to ensure things are correct and to discuss changes, etc. so we can manage you best type of thing. I even sometimes go further and say, any good doctor should ask you about changes, your medications, etc. when you are new to them. After that, I generally don't hear any more about "the chart."

 

[PlutoBoy]

Even BETTER is when they're a brand new patient from a whole other country. No, we don't have immediate access to your paper chart in Bangladesh.

What do you mean you don't? /sarcasm

 

[killerleaf]

Maybe it is different where you are, but in our clinics, patients see: the medical student, the resident, then the attending. Who all ask the same questions. DURING THE SAME APPOINTMENT. Yeah, it gets frustrating from a patient point of view when you say the same thing three times.

 

[mcl]

Maybe it is different where you are, but in our clinics, patients see: the medical student, the resident, then the attending. Who all ask the same questions. DURING THE SAME APPOINTMENT. Yeah, it gets frustrating from a patient point of view when you say the same thing three times.

This! Not to mention the 5 pages of paperwork I completed prior to my Ortho appointment detailing my history, why I was there, and what I expected--which seemed to disappear once I turned it into the front desk. Because EVERY person asked me exactly the same questions I had spent significant time/thought writing out responses to "because they wanted to hear it from me." I was so frustrated by the time I got to the OT person (the fifth person I saw) that I felt like screaming.

 

[smq123]

Maybe it is different where you are, but in our clinics, patients see: the medical student, the resident, then the attending. Who all ask the same questions. DURING THE SAME APPOINTMENT. Yeah, it gets frustrating from a patient point of view when you say the same thing three times.

But they say it even to me - an attending who sees patients without a medical student or a resident. The only person that they've talked to before me is the medical assistant (who really just puts in vitals and a chief complaint).

 

[killerleaf]

Then that is irritating!!

 

[Pes anserine]

But they say it even to me - an attending who sees patients without a medical student or a resident. The only person that they've talked to before me is the medical assistant (who really just puts in vitals and a chief complaint).

Today I had a patient who kept Being rude and telling me about the different possible diagnosis he could have and making a fool out of himself by pretending like he had all this medical knowledge. I actually had to kind of put him in his place because he was being super belligerent - I had to tell him I was trying to help him and basically that he had to tone it down.

 

[FutureInternist]

I do only inpt so the H&P usually is only revolving around one issue.

I just say "I reviewed your chart & talked to Dr Smith & based on what I know...........". I do this because by the time they see me, they have told their story to their spouse, 911, EMS, ER triage nurse, ER nurse, ER doc & then me, so it helps that they know that I put in the effort to review everything & hopefully it is less frustrating.

This also prevents elongated H&P time where they keep trying to think of the time the chest pain started, when really their labs & EKGs have already told me what I am going to do, so whether it was 2pm or 4 pm makes no difference.

 

[rokshana]

Today I had a patient who kept Being rude and telling me about the different possible diagnosis he could have and making a fool out of himself by pretending like he had all this medical knowledge. I actually had to kind of put him in his place because he was being super belligerent - I had to tell him I was trying to help him and basically that he had to tone it down.

my sister can be that person...grew up in a houseful of doctors so she has some understanding, but..one time she called my dad (a doctor) and said she was going to the the doctor for something and asked what should she tell the doctor about what she thought her issue was and he said to her...tell him what is going on, symptoms, timeline, etc....and then let the doctor be the doctor....I tell that story to some pts when THEY are trying to be the doctor.

 

[TraumaLlamaMD]

Maybe it is different where you are, but in our clinics, patients see: the medical student, the resident, then the attending. Who all ask the same questions. DURING THE SAME APPOINTMENT. Yeah, it gets frustrating from a patient point of view when you say the same thing three times.

Maybe if they stopped changing their story between interviews, we wouldn’t have to ask so many times! How many times has a patient told you “nope, never had surgery” only to remember “unless you mean that time I had my colon out ten years ago, does that count?” by the time your attending walks in?

 

[FutureInternist]

Maybe if they stopped changing their story between interviews, we wouldn’t have to ask so many times! How many times has a patient told you “nope, never had surgery” only to remember “unless you mean that time I had my colon out ten years ago, does that count?” by the time your attending walks in?

The "Attending Sign"...every intern & resident's nightmare.

 

[killerleaf]

And I apologize, but that was my dad. In his defense, he had many procedures and he never could remember all of them. Heck, even Mom had problems remembering them all for him!

 

[Pes anserine]

my sister can be that person...grew up in a houseful of doctors so she has some understanding, but..one time she called my dad (a doctor) and said she was going to the the doctor for something and asked what should she tell the doctor about what she thought her issue was and he said to her...tell him what is going on, symptoms, timeline, etc....and then let the doctor be the doctor....I tell that story to some pts when THEY are trying to be the doctor.

It's one thing if a patient has questions, asks me if I think this or that could be helpful, etc but this patient was outright rude and unacceptable - I don't think I've ever had to tell a patient essentially to calm down. What kind of person tells the physician about the different possible types of diagnoses, that I should know what this or that medication does, etc. I told the chief of the dept., who I think really made the patient feel stupid when they kept up the ridiculousness.

 

[WhiteCoatWonder]

...I had a pt today who essentially wanted me to construct a whole H&P via chart review, meh. I just ended up saying "I'm sorry, but you have hundreds of notes in your chart and often the information in your chart is incorrect so I prefer to hear it from you. If there's something you don't remember, that's okay and we can use the chart to fill in some details."

student checkin' in, so grain-of-salt me if need be, but i say this too.

as the 15th or 50th person taking a pt history, i find that ive gotten lots of good data from curmudgeons by smiling a lot, starting with "ohhh im so sorry you're feeling bad" and then going into "do you mind if i ask a few more questions?" (even if its the whole H+P).

i do try to rapid-fire chart biopsy as much as i can before seeing them, so the exchange is more of a give and take...ie "was that before or after your colectomy? in '92 right?" and "i have that your FH includes xyz, has anything changed?" etc, etc.

or maybe you could try telling them that the EMR is down, so we cant see anything??? only if it is, of course

 

[Bacchus]

I tell them "It's a test" and chuckle. Usually goes over well. The only time I really feel all of this to be too much is when I see another provider's patient (FMLA, vacation, etc.) who I have not seen before because in those instances I do go over almost everything often telling the patients, "so and so 'doctor' differently and I want to make sure I know you." This at least lets me get my mind in the right place. It's also helpful so you can get your HCC complexity where it needs to be. I see so many Epic problem lists with T2DM without complications when they have CKD, retinopathy or neuropathy and/or all of the above.

 

[obgyny]

I agree with doing as much chart dissection as you can, so that you can summarize what you know to show the patient you did read the chart. "But I want to hear some of the details from you." or "But I'd like to ask you a little bit more detail about X." Or you can always use, "I just want to make sure your chart is up to date, do you have any other medical issues aside from diabetes? Any other surgeries aside from the appendectomy? etc etc."

And I do understand the frustrations patients have with being asked the same questions a million times by the nurse, the med student, the resident, and the attending, etc. So I try to acknowledge that I spoke to the person before me:

"Thank you for talking with Susie, my medical student. She tells me that X,Y,Z happened and you've been feeling A,B,C. Can you tell me more about X?"

"So I spoke with the ER doctor taking care of you and heard X, Y, Z, I just wanted to ask you about X..."

 

[FutureInternist]

In an effort to help out any doc that crosses paths with my family, I typed up a one page synopsis with instructions to take to all appts.

 

[rokshana]

In an effort to help out any doc that crosses paths with my family, I typed up a one page synopsis with instructions to take to all appts.

actually, i kinda like those patients, so much better than having to spend 75% of the visit just trying to get simple information. And if their history is complicated or detailed it is nice that its all listed out on a couple (of few ) pages.

 

[Raryn]

actually, i kinda like those patients, so much better than having to spend 75% of the visit just trying to get simple information. And if their history is complicated or detailed it is nice that its all listed out on a couple (of few ) pages.

Until their synopsis also includes their recommendations from their naturopath, chinese herbalist, and chiropracter, as well as extensive photos of the head of their penis for their (mostly self-inflicted due to "treatment" efforts) balantitis. Then I don't appreciate it.

But otherwise, yes. I agree with all of the above. Just sweet talk the patient, ask them some "confirmatory" questions to show you read what you could, and you'll typically be fine. Most people are reasonable.

 

[WhiteCoatWonder]

actually, i kinda like those patients, so much better than having to spend 75% of the visit just trying to get simple information. And if their history is complicated or detailed it is nice that its all listed out on a couple (of few ) pages.

agreed...i met a patient who had an extensive med list. her daughter was a pharmacist and gave her a 5x8 with her meds on it to take with her to appointments. i think i may have shed a tear.

 

[Siggy]

The "Attending Sign"...every intern & resident's nightmare.

Ah, good old Historian Alternans. The bane of many a medical student and resident.

 

[RadOncDoc21]

I absolutely hate the review of systems. I literally can’t address all 600 responses in a reasonable manner nor should I have to.

 

[Psai]

I absolutely hate the review of systems. I literally can’t address all 600 responses in a reasonable manner nor should I have to.

"12 point review of systems reviewed and found to be negative except as above"

 

[PlutoBoy]

I absolutely hate the review of systems. I literally can’t address all 600 responses in a reasonable manner nor should I have to.

I ask about chest pain/sob/melena/hematochezia/hematuria/ moles.

If negative and patient says nothing else, ROS is negative "per HPI".

 

[RadOncDoc21]

"12 point review of systems reviewed and found to be negative except as above"

Oh trust me I learned how to streamline it much better, but it def sucked as a resident to obtain.

My only problem these days is getting my staff to focus in on the pertinent positives. I have one nurse that always tries to “find” something wrong with every patient. The form we have in our office is about 5 pages of symptoms. I didn’t even know you could have so many problems!

 

[geauxg8rs]

Oh trust me I learned how to streamline it much better, but it def sucked as a resident to obtain.

My only problem these days is getting my staff to focus in on the pertinent positives. I have one nurse that always tries to “find” something wrong with every patient. The form we have in our office is about 5 pages of symptoms. I didn’t even know you could have so many problems!

My favorite is going off the generic body diagram i have patients fill out prior to seeing them. They are to highlight where it hurts. It is amazing how many times patients get it wrong.
So I reaffirm “you have pain down your right arm.”
I actually had a gem of a patient say I was an idiot for not knowing left from right. he shut up quickly when i showed him his diagram and said i was just going off what he wrote

Oh sorry doc

My second favorite are the old men (never women) who don’t know their allergies. Apparently keeping track of allergies is women’s work. Just ask my wife she knows.

 

[NotAProgDirector]

When I work with a medical student, after they have seen the patient I have them present to me in front of the patient. I explain that the student is going to review what they found, and afterwards I'll be asking the patient if there's anything that got missed.

 

[NotAProgDirector]

I ask about chest pain/sob/melena/hematochezia/hematuria/ moles.

If negative and patient says nothing else, ROS is negative "per HPI".

This is billing fraud (I think?) if any of your billing codes were higher than a level 1. We could make lots of money off it, if you're interested.

 

[Perrotfish]

When I work with a medical student, after they have seen the patient I have them present to me in front of the patient. I explain that the student is going to review what they found, and afterwards I'll be asking the patient if there's anything that got missed.

Oh f--k that.

"This is Mr. Schmucketelli, a 57 year old male with cough and congestion x 3 days. ummm...

maybe he has cancer?"

Medical students are strictly forbidden from verbalizing their assessment or plan within earshot of my patients. Ditto Interns. Otherwise it take three office visits and an MRI to convince the patient that they don't have the thing the 'other doctor' said they might have.

 

[Rendar5]

This is billing fraud (I think?) if any of your billing codes were higher than a level 1. We could make lots of money off it, if you're interested.

‘ all systems reviewed and are otherwise negative except as stated in the hpi” does actually work for billing and I have seen something similar used on multiple emr’s as well as t-sheets at least in Emergency Medicine. That said I do ask one thing from every system during my exam regardless.

 

[PlutoBoy]

This is billing fraud (I think?) if any of your billing codes were higher than a level 1. We could make lots of money off it, if you're interested.

I see your point but I'm not saying all negative. I'm saying per HPI. Do you really ask all of your patients that present to the clinic if they have felt hot or cold?

 

[PlutoBoy]

‘ all systems reviewed and are otherwise negative except as stated in the hpi” does actually work for billing and I have seen something similar used on multiple emr’s as well as t-sheets at least in Emergency Medicine. That said I do ask one thing from every system during my exam regardless.

Well, if I didn't ask one thing from every system I shouldn't write all systems reviewed and negative. That would be fraud.

Having said that, it is not necessary to review every system even for a level four visit:

You need two out of those three components.
So when I ask chest pain/sob/palpitations/melena/hematuria I am indeed performing a level 4 ROS.

 

[hamstergang]

Well, if I didn't ask one thing from every system I shouldn't write all systems reviewed and negative. That would be fraud.

Having said that, it is not necessary to review every system even for a level four visit:

View attachment 225299

You need two out of those three components.
So when I ask chest pain/sob/palpitations/melena/hematuria I am indeed performing a level 4 ROS.

As this demonstrates, for follow up visits people don't need to do or claim to do a full ROS. Two elements each from 2 separate systemd will suffice for near every visit. I'm not sure why this doesn't seem as commonly known nor implemented as it should be.

Certainly stating that all systems negative or ROS otherwise negative without asking about all systems is fraudulent.

 

[RadOncDoc21]

My thing is why does it matter? Shouldn’t it be enough to provide great medical care without redundant documentation? I believe we over document and a lot gets lost in the EMR system. Why does an inpatient chart have 100 separate notes in the span of 24 hrs?

 

[rokshana]

I see your point but I'm not saying all negative. I'm saying per HPI. Do you really ask all of your patients that present to the clinic if they have felt hot or cold?

lol I do!!
but then i'm endo, so asking " do you feel hot when everyone feels cold or do you feel cold when everyone is hot" is a given...

 

[PlutoBoy]

lol I do!!
but then i'm endo, so asking " do you feel hot when everyone feels cold or do you feel cold when everyone is hot" is a given...

 

[smq123]

Oh f--k that.

"This is Mr. Schmucketelli, a 57 year old male with cough and congestion x 3 days. ummm...

maybe he has cancer?"

Medical students are strictly forbidden from verbalizing their assessment or plan within earshot of my patients. Ditto Interns. Otherwise it take three office visits and an MRI to convince the patient that they don't have the thing the 'other doctor' said they might have.

Haha, once I had a med student who was the complete opposite. She told a patient (a guy in his 50s, with diabetes) that his worsening chest pain and dyspnea on exertion was “probably just a sign that you need to exercise more. Nothing to worry about!”

Fortunately, he was skeptical and was more than willing to do a stress test.

 

[Raryn]

This is billing fraud (I think?) if any of your billing codes were higher than a level 1. We could make lots of money off it, if you're interested.

Technically yes, at least for initial consults/visits. For followups (as above) it would be fraudulent documentation, but probably not necessary to meet the coding requirements. Regardless, would probably be difficult to prove.

 

[PlutoBoy]

Technically yes, at least for initial consults/visits. For followups (as above) it would be fraudulent documentation, but probably not necessary to meet the coding requirements. Regardless, would probably be difficult to prove.

If I write a limited ROS on the HPI and then under ROS write "per HPI" how is that fraudulent?

It is one thing to say "per HPI" and another to say "all systems reviewed and negative".

 

[PlutoBoy]

I am actually very strict about these things. That's one reason why I don't like templates - they tend to document more than what was actually done.

For example, 99% of the time
I'm not looking for PMI on my cardiovascular exam but our EHR includes it in the template of a normal exam.

I can't imagine a surgeon seeing a patient for biliary cholic and asking the patient if they had felt any tingling and numbness in their feet.

Simply stated, doing these things is not necessary. It's not fraud as long as you accurately document what you did and your documentation supports the level of care you are billing for.

I'm having a hard time understanding your train of thought. I'm open to being educated. I'm very particular about these things and probably underbill because of this.

 

[FutureInternist]

Just bill by time, then you don’t have to worry about how many ROS and how many PE points you hit

 

[Donald Juan]

Just bill by time, then you don’t have to worry about how many ROS and how many PE points you hit

Yeah, but then you have to make sure your visits add up. You can't have a 40 patient clinic and say you spent 45 minutes with all of them.

 

[PlutoBoy]

Just bill by time, then you don’t have to worry about how many ROS and how many PE points you hit

That's probably the easiest way to do it.

What I've heard from coders is this:

"Ask two coders what level should be billed and get two different answers."

Medicare is not expecting perfection. But if all of your visits are 99214 and 99215, you better have the documentation to back it up.

Internists choose 99214 in about 45% of their patient encounters, IIRC. If you find yourself billing 99214 in 90% of your encounters, you may want to review what you are doing and make sure that it supports that level of care.

 

[mvenus929]

Oh f--k that.

"This is Mr. Schmucketelli, a 57 year old male with cough and congestion x 3 days. ummm...

maybe he has cancer?"

Medical students are strictly forbidden from verbalizing their assessment or plan within earshot of my patients. Ditto Interns. Otherwise it take three office visits and an MRI to convince the patient that they don't have the thing the 'other doctor' said they might have.

I didn't have my med students and interns present their assessment and plan, just review the history in front of the patient. Then I'd ask whatever I perceived that they missed and give a vague plan to the patient (usually like 'alright, we're going to get you upstairs and continue the antibiotic for now'). Then outside the room, they would give me their assessment and plan.

 

[Perrotfish]

I didn't have my med students and interns present their assessment and plan, just review the history in front of the patient. Then I'd ask whatever I perceived that they missed and give a vague plan to the patient (usually like 'alright, we're going to get you upstairs and continue the antibiotic for now'). Then outside the room, they would give me their assessment and plan.

That just seems backwards. Don't they just parrot what you said just back at you? Even a vague plan (continue the antibiotics) is a pretty big hint (Huh, guess it wasn't a virus after all).

I want to give them the opportunity to completely flop, so I can get them to the point where they are actually giving a good assessment and plan. Just not in front of the patient.

 

[mvenus929]

That just seems backwards. Don't they just parrot what you said just back at you? Even a vague plan (continue the antibiotics) is a pretty big hint (Huh, guess it wasn't a virus after all).

I want to give them the opportunity to completely flop, so I can get them to the point where they are actually giving a good assessment and plan. Just not in front of the patient.

That's fair. I've only done this in the setting of admission to the hospital, and usually at that point, there's still lab tests we're waiting on. I also coach them a bit before they go down to talk to the patient (this is their chief complaint, what could it be, and what questions should you ask... these labs have come back, does that change your differential). For things like 'infant with a fever', it could very well be a virus, but we're still going to continue antibiotics for 24-36 hours.

I also focus on different things with different patients. I want to hear the student talk to the family sometimes, so I'll sit in the corner and when the student gives up, I"ll take over and ask clarifying questions. It allows me to see how well they take their history, and them an opportunity to see how I ask questions. When they go down on their own, we focus more on A/P.

 

[FutureInternist]

Yeah, but then you have to make sure your visits add up. You can't have a 40 patient clinic and say you spent 45 minutes with all of them.

I am a hospitalist and we were told that we could have overlapping times in that you could be working with Case Management about several patients at once.

I believe ICU is NOT allowed to overlap.

New people from overnight admits, I bill highest, people going home tomorrow, I bill lowest. The rest just wing it

 

[hmockingbird]

I usually just sweet talk them with something about "confirming things" but I like the idea of the joking "it's a test" haha. I also like (in clinic) to look at the last note and follow up any symptoms and usually people appreciate that.

The main exception would be complicated patients on speciality services who have a really good recently documented history (some of our specialties are exceptional at this). In that case I broadly go over the highlights of the history to confirm and make sure that I have the updated meds. I ask more detailed questions if something in the history I read seems especially relevant to the admission.