"It's all in my chart."

[smq123]

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 other issue with patients who insist that it's all "already in my chart" is that they frequently don't know how poorly some physicians and midlevels can document. I once worked with a PA who had the worst documentation in the world. Literally, there was no HPI, just a bunch of symptoms and a few pertinent negatives (if we were lucky). I remember once I read a chart that he had written where the chief complaint (entered by the medical assistant) was "shoulder pain." The diagnosis in the assessment? BPH. How they got from shoulder pain to BPH in that visit was a total mystery, because there was literally nothing in the HPI or ROS. So whenever I saw a patient who had seen him, and they insisted that their history was "already in the chart," it was hard not to audibly groan.

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[Bacchus]

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

Isn't it direct, face to face coordination of care? In the outpatient setting it is. Talking with CM, SW, nursing DOES NOT count for us. 30 minute chart review? Nope, doesn't count, unless you're actively doing it in the room and the patient is engaged.

 

[FutureInternist]

Isn't it direct, face to face coordination of care? In the outpatient setting it is. Talking with CM, SW, nursing DOES NOT count for us. 30 minute chart review? Nope, doesn't count, unless you're actively doing it in the room and the patient is engaged.

Hmm.. not 100% sure.

If I remember correctly there is a component of corodinating care on patient’s floor, which unit based rounds would count towards.

I do count reviewing the H&P with pt, discussing their meds upon DC, which pharmacy they want meds to go to, who’s going to pick them up, do they need a ride, etc.

 

[rokshana]

Isn't it direct, face to face coordination of care? In the outpatient setting it is. Talking with CM, SW, nursing DOES NOT count for us. 30 minute chart review? Nope, doesn't count, unless you're actively doing it in the room and the patient is engaged.

no...> than 50% has to be face to face...and in the inpt setting, the pt isn't alway that engagable...

 

[Trismegistus4]

The other issue with patients who insist that it's all "already in my chart" is that they frequently don't know how poorly some physicians and midlevels can document. I once worked with a PA who had the worst documentation in the world. Literally, there was no HPI, just a bunch of symptoms and a few pertinent negatives (if we were lucky).

hahaha
this reminds me of an NP
who worked at the VA when I was in residency
her HPIs/subjective sections read like this
it was just a stream-of-consciousness
of whatever the patient said
translated into the 3rd person as she typed
with no capitalization or punctuation
and line breaks at random places
so that it looked like postmodern poetry

 

[gutonc]

hahaha
this reminds me of an NP
who worked at the VA when I was in residency
her HPIs/subjective sections read like this
it was just a stream-of-consciousness
of whatever the patient said
translated into the 3rd person as she typed
with no capitalization or punctuation
and line breaks at random places
so that it looked like postmodern poetry

One of my former partners notes were like that. Stream of consciousness, rarely relevant to the issue at hand.

 

[Raryn]

One of my former partners notes were like that. Stream of consciousness, rarely relevant to the issue at hand.

I know a couple posters on SDN that are like that too.

 

[gutonc]

I know a couple posters on SDN that are like that too.

Well yeah...but they don't bill for that.

 

[HomeSkool]

When I see patients in preop holding, I generally warn them to expect a parade of people asking all the same questions. I tell them to make sure they've got their story straight, which usually gets a laugh.

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