Reviewing MLP charts. FUN TIMES!

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RustedFox said:
This is what I have to sign every shift.
I actually copy-pasted the HPI from this MLP's chart.



The patient presents with Vision is brought in by his wife and daughter for weakness fever recorded at 101 given Tylenol approximately 45 minutes 1 g prior to arrival by daughter. Generally feeling weak with near syncopal episodes. The onset was 2 days ago. The course/duration of symptoms is worsening. The character of symptoms is generalized, lack of stamina and lack of strength. The degree at present is moderate. Risk factors consist of none. Prior episodes: frequent. Therapy today: none. Associated symptoms: none.
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I mean I guess it'd be even more problematic if the patient presented without vision. Hoping Vision is name of an ambulance company or something.

My goodness. This is like how people who don't speak english would speak english.
 
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RustedFox said:
I don't see why we don't sedate a LOT of things.
I sedate all my procedures. Every single one. Central lines (that aren't dying). LPs. Reductions. Even lac repairs that are time-consuming.
It makes it so easy.
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TooMuchResearch said:
On really sick patients it often causes hypotension. Or rather they get hypotension after receiving the med. That's been my experience. I think there was an Annals of EM on it in the prehospital setting.
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Why not give some peripheral vasopressors (they're safe) + sedation), put the line in and then transition to central vasopressors?
 
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RustedFox said:
This is what I have to sign every shift.
I actually copy-pasted the HPI from this MLP's chart.



The patient presents with Vision is brought in by his wife and daughter for weakness fever recorded at 101 given Tylenol approximately 45 minutes 1 g prior to arrival by daughter. Generally feeling weak with near syncopal episodes. The onset was 2 days ago. The course/duration of symptoms is worsening. The character of symptoms is generalized, lack of stamina and lack of strength. The degree at present is moderate. Risk factors consist of none. Prior episodes: frequent. Therapy today: none. Associated symptoms: none.
Click to expand...

Isn't this just the result of "writing" the HPI by clicking through the EMR checkboxes? This is why I never check them and just free-text my narrative.
 
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RustedFox said:
This is what I have to sign every shift.
I actually copy-pasted the HPI from this MLP's chart.



The patient presents with Vision is brought in by his wife and daughter for weakness fever recorded at 101 given Tylenol approximately 45 minutes 1 g prior to arrival by daughter. Generally feeling weak with near syncopal episodes. The onset was 2 days ago. The course/duration of symptoms is worsening. The character of symptoms is generalized, lack of stamina and lack of strength. The degree at present is moderate. Risk factors consist of none. Prior episodes: frequent. Therapy today: none. Associated symptoms: none.
Click to expand...
I can't stop laughing.
 
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RustedFox said:
This is what I have to sign every shift.
I actually copy-pasted the HPI from this MLP's chart.



The patient presents with Vision is brought in by his wife and daughter for weakness fever recorded at 101 given Tylenol approximately 45 minutes 1 g prior to arrival by daughter. Generally feeling weak with near syncopal episodes. The onset was 2 days ago. The course/duration of symptoms is worsening. The character of symptoms is generalized, lack of stamina and lack of strength. The degree at present is moderate. Risk factors consist of none. Prior episodes: frequent. Therapy today: none. Associated symptoms: none.
Click to expand...

In all fairness, I see a lot of doctors’ charts that are like this. Who knows if it’s laziness, or something to do with the scribe, or both, but this is my worst nightmare.
 
This MLP is going to get a sit-down meeting sometime here soon.
I work with a doc who is as bad with his charting.
Difference is: I don't have to answer for the doc. He can answer for himself.
I've been at this job site for four years. He hasn't improved one iota despite multiple heart-to-heart talks about the issue.
I'm going to say to him: "Dude. I can tell one thing for certain; you don't read your charts."
 
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Maybe refer this mlp to the impaired provider program?

Sounds like your MLPs suck.
 
GeneralVeers said:
I sedate pretty much ever peds I have to do a lac repair, I&D or other painful procedure. Adults gets sedation for all chest tubes when Ketamine. I usually only do central lines on intubated patients. Unfortunately can't use on conscious central lines because most of the time the reason I'm putting it in is hypotension.
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Issue for me is that most of these septic, hypotensive patients are already very tachycardic. Ketamine could make things worse.
 
enalli said:
Isn't this just the result of "writing" the HPI by clicking through the EMR checkboxes? This is why I never check them and just free-text my narrative.
Click to expand...

I actually do both. I check all the boxes to make the nonsense HPI we are all used to reading, but it is necessary to capture all components of the HPI for billing. I then free-text a completely separate 1-2 sentence HPI that that tells the story in a readable format.
 
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GeneralVeers said:
Issue for me is that most of these septic, hypotensive patients are already very tachycardic. Ketamine could make things worse.
Click to expand...
Agree with what was said above. Peripheral pressors --> stable vitals --> light sedation with versed or just use ketamine --> CVL in, pressors transitioned to CVL, patient to ICU.
 
RustedFox said:
This is what I have to sign every shift.
I actually copy-pasted the HPI from this MLP's chart.



The patient presents with Vision is brought in by his wife and daughter for weakness fever recorded at 101 given Tylenol approximately 45 minutes 1 g prior to arrival by daughter. Generally feeling weak with near syncopal episodes. The onset was 2 days ago. The course/duration of symptoms is worsening. The character of symptoms is generalized, lack of stamina and lack of strength. The degree at present is moderate. Risk factors consist of none. Prior episodes: frequent. Therapy today: none. Associated symptoms: none.
Click to expand...


(Cue Samuel L. Jackson voice)

ENGLISH, MOTHER*******. DO YOU SPEAK IT?!?!?
 
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It shouldn't make it worse. They're already maxing out any catecholamine reserve they have left, ketamine shouldn't make them more tachycardic. It definitely makes non-critically ill patients more tachy (i.e. the Peds sedations).
GeneralVeers said:
Issue for me is that most of these septic, hypotensive patients are already very tachycardic. Ketamine could make things worse.
Click to expand...
 
GeneralVeers said:
I actually do both. I check all the boxes to make the nonsense HPI we are all used to reading, but it is necessary to capture all components of the HPI for billing. I then free-text a completely separate 1-2 sentence HPI that that tells the story in a readable format.
Click to expand...

I do this as well. I click the boxes for the coders/billers, then I dictate the things that actually need to be said such that my fellow physicians can read something that makes sense.

If you're not dictating some sort of a summary, you're doing it wrong. That's how you end up with a patient presenting with "Vision".
 
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RustedFox said:
I do this as well. I click the boxes for the coders/billers, then I dictate the things that actually need to be said such that my fellow physicians can read something that makes sense.

If you're not dictating some sort of a summary, you're doing it wrong. That's how you end up with a patient presenting with "Vision".
Click to expand...

So what did your PA do for this "worsening" and "moderate" Vision that the patient was there for?
 
This is probably one of those "it's 4 AM and I shouldn't have wasted the last 30 minutes of my life reading this inane cluster**** of a discussion" replies, but we're all here because it's the interwebs and we can bitch at strangers, so here ya go:

Fox: you apparently only work with *****s and arrogant blowhards, at least one of whom has recently put you through a lawsuit, so I genuinely feel some small degree of empathy towards your work environment, but you live in Florida it seems, so like, what'd you expect? IT'S FLORIDA. Seriously though, "worsening and moderate Vision" is probably what that PA has from all the oxycodone one of your colleagues is prescribing him at their strip mall pain clinic, so you should definitely refer him for testing. I've never witnessed malpractice in both charting and patient care like you've described.

Dr. Strangelove: I like you. You own it. I have the best working relationships with attendings with whom I know where I stand.

"Genius": I'm sorry your college jam band didn't work out, so you're stuck educating us plebeians on pretest probabilities for $300/hr. Take some solace in the fact that despite rolling the dice on getting sued for patients you never saw that you try and practice good medicine over defensive medicine with your own patients.

Boats: keep doing you, sir. Let the NPs keep recommending essential oils in their independent practice; they'll eventually be the cause of their own demise. We gotta keep the PA profession on track.

CatLady: you're on the right path. Keep building good relationships with your docs and learning all you can, just remember that while half of them appreciate your amazing catches, half of them despise having to deal with you on a daily basis. And it's cute you believe that referring providers to administration for "education" and "corrective action" is even a remotely worthwhile task. Give it time, and one day you'll see the evil in corporate medicine too.

I left the ED for critical care a few years back, because yeah, PAs can do that, but in trying to move closer to home, the only job that will pay me what I'm making now is back in the ED with one of the CMGs. I thought SDN would have some insight for me, but I'm definitely no closer to deciding if the money is worth dealing with door-to-greet metrics and condescending attendings again.
 
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arm7d said:
This is probably one of those "it's 4 AM and I shouldn't have wasted the last 30 minutes of my life reading this inane cluster**** of a discussion" replies, but we're all here because it's the interwebs and we can bitch at strangers, so here ya go:

PenisFox: you apparently only work with *****s and arrogant blowhards, at least one of whom has recently put you through a lawsuit, so I genuinely feel some small degree of empathy towards your work environment, but you live in Florida it seems, so like, what'd you expect? IT'S FLORIDA. Seriously though, "worsening and moderate Vision" is probably what that PA has from all the oxycodone one of your colleagues is prescribing him at their strip mall pain clinic, so you should definitely refer him for testing. I've never witnessed malpractice in both charting and patient care like you've described.

Dr. Strangelove: I like you. You're an asshat and you own it. I have the best working relationships with attendings with whom I know where I stand.

"Genius": I'm sorry your college jam band didn't work out, so you're stuck educating us plebeians on pretest probabilities for $300/hr. Take some solace in the fact that despite rolling the dice on getting sued for patients you never saw that you try and practice good medicine over defensive medicine with your own patients.

Boats: keep doing you, sir. Let the NPs keep recommending essential oils in their independent practice; they'll eventually be the cause of their own demise. We gotta keep the PA profession on track.

CatLady: you're on the right path. Keep building good relationships with your docs and learning all you can, just remember that while half of them appreciate your amazing catches, half of them despise having to deal with you on a daily basis. And it's cute you believe that referring providers to administration for "education" and "corrective action" is even a remotely worthwhile task. Give it time, and one day you'll see the evil in corporate medicine too.

I left the ED for critical care a few years back, because yeah, PAs can do that, but in trying to move closer to home, the only job that will pay me what I'm making now is back in the ED with one of the CMGs. I thought SDN would have some insight for me, but I'm definitely no closer to deciding if the money is worth dealing with door-to-greet metrics and condescending attendings again.
Click to expand...
That was a weirdly personal escalation
 
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Aww man, I knew I should have replied more to this thread so I could have been included in the 4a.m. MLP hemiballismus "pimp slap". :rofl:

LOL@ "PenisFox"

Fox, you gotta start using that one in your signature.
 
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skibumn said:
This is probably one of those "it's 4 AM and I shouldn't have wasted the last 30 minutes of my life reading this inane cluster**** of a discussion" replies, but we're all here because it's the interwebs and we can bitch at strangers, so here ya go:

PenisFox: you apparently only work with *****s and arrogant blowhards, at least one of whom has recently put you through a lawsuit, so I genuinely feel some small degree of empathy towards your work environment, but you live in Florida it seems, so like, what'd you expect? IT'S FLORIDA. Seriously though, "worsening and moderate Vision" is probably what that PA has from all the oxycodone one of your colleagues is prescribing him at their strip mall pain clinic, so you should definitely refer him for testing. I've never witnessed malpractice in both charting and patient care like you've described.

Dr. Strangelove: I like you. You're an asshat and you own it. I have the best working relationships with attendings with whom I know where I stand.

"Genius": I'm sorry your college jam band didn't work out, so you're stuck educating us plebeians on pretest probabilities for $300/hr. Take some solace in the fact that despite rolling the dice on getting sued for patients you never saw that you try and practice good medicine over defensive medicine with your own patients.

Boats: keep doing you, sir. Let the NPs keep recommending essential oils in their independent practice; they'll eventually be the cause of their own demise. We gotta keep the PA profession on track.

CatLady: you're on the right path. Keep building good relationships with your docs and learning all you can, just remember that while half of them appreciate your amazing catches, half of them despise having to deal with you on a daily basis. And it's cute you believe that referring providers to administration for "education" and "corrective action" is even a remotely worthwhile task. Give it time, and one day you'll see the evil in corporate medicine too.

I left the ED for critical care a few years back, because yeah, PAs can do that, but in trying to move closer to home, the only job that will pay me what I'm making now is back in the ED with one of the CMGs. I thought SDN would have some insight for me, but I'm definitely no closer to deciding if the money is worth dealing with door-to-greet metrics and condescending attendings again.
Click to expand...
Image result for meltdown gif
 
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GeneralVeers said:
Issue for me is that most of these septic, hypotensive patients are already very tachycardic. Ketamine could make things worse.
Click to expand...

Often they don't need a full dose to keep them calm during an Central line. So I'll give 0.5 mg/kg IV or 0.75 mg/kg IV...there aren't too many problems with that. But you still need a nurse with ya in the room to make sure they don't start moving around and ruining your sterile field.

in my experience...
 
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I must have a really soothing voice... I rarely need sedation for chest tubes or CVLs. I tell them if they jerk, I'm going to accidentally slice their carotid and they'll bleed to death in less than 2 mins. Same with chest tubes, I tell them if they jerk, I'm going to puncture their heart and it will, in fact, explode in their chest. They stay remarkably still for me. The rest...I find some reason to tube and paralyze prior to the procedure. I kid, I kid....ahem.
 
skibumn said:
This is probably one of those "it's 4 AM and I shouldn't have wasted the last 30 minutes of my life reading this inane cluster**** of a discussion" replies, but we're all here because it's the interwebs and we can bitch at strangers, so here ya go:

Fox: you apparently only work with *****s and arrogant blowhards, at least one of whom has recently put you through a lawsuit, so I genuinely feel some small degree of empathy towards your work environment, but you live in Florida it seems, so like, what'd you expect? IT'S FLORIDA. Seriously though, "worsening and moderate Vision" is probably what that PA has from all the oxycodone one of your colleagues is prescribing him at their strip mall pain clinic, so you should definitely refer him for testing. I've never witnessed malpractice in both charting and patient care like you've described.

Dr. Strangelove: I like you. You own it. I have the best working relationships with attendings with whom I know where I stand.

"Genius": I'm sorry your college jam band didn't work out, so you're stuck educating us plebeians on pretest probabilities for $300/hr. Take some solace in the fact that despite rolling the dice on getting sued for patients you never saw that you try and practice good medicine over defensive medicine with your own patients.

Boats: keep doing you, sir. Let the NPs keep recommending essential oils in their independent practice; they'll eventually be the cause of their own demise. We gotta keep the PA profession on track.

CatLady: you're on the right path. Keep building good relationships with your docs and learning all you can, just remember that while half of them appreciate your amazing catches, half of them despise having to deal with you on a daily basis. And it's cute you believe that referring providers to administration for "education" and "corrective action" is even a remotely worthwhile task. Give it time, and one day you'll see the evil in corporate medicine too.

I left the ED for critical care a few years back, because yeah, PAs can do that, but in trying to move closer to home, the only job that will pay me what I'm making now is back in the ED with one of the CMGs. I thought SDN would have some insight for me, but I'm definitely no closer to deciding if the money is worth dealing with door-to-greet metrics and condescending attendings again.
Click to expand...

ERCat... CatLady... same thing. I just appreciate that someone read my crap.
 
Mr. Hat said:
Q: Why didn't you order XYZ?
A: No idea, I didn't see the patient
Q: Don't you think the chart indicates that XYZ should have been done but wasn't?
A: No idea, I can't comment about care on a patient I didn't see
Q: Why didn't you see them?
A: My hospital tells me MLP's see patients on their own, and they decide whether or not to consult me
Q: Don't you think a doctor should be seeing these patients?
A: No one even told me they were there. I didn't get record they had even been there until hours after they were discharged.
Q: But don't you think you should have followed up on them?
A: No idea, I can't comment about care on a patient I didn't see.

And so on and so forth. System is what it is. I'm not working an extra minute for something that isn't my fault and isn't my problem. Chips fall where they may. Am I alone in this?
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Nope, you're not alone. This is precisely what I do. Most of the EDPAs I've worked with are pretty good. The NPs on the other hand...
 
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UPDATE:

All existing MLPs at my primary job site have been replaced along with our CMG changing hands and our "shift map" changing to reflect more physician hours and far less MLP hours.

All of them.

Every single last one.

We have hired two new PAs (no NPs) and the message has been sent to these new hires that: "You're not here to argue; you're here to see low acuity things quickly, not try and pick up 2's and 3's and argue with us about "how you would do it differently".
 
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RustedFox said:
UPDATE:

All existing MLPs at my primary job site have been replaced along with our CMG changing hands and our "shift map" changing to reflect more physician hours and far less MLP hours.

All of them.

Every single last one.

We have hired two new PAs (no NPs) and the message has been sent to these new hires that: "You're not here to argue; you're here to see low acuity things quickly, not try and pick up 2's and 3's and argue with us about "how you would do it differently".
Click to expand...

This is the dream.
 
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RustedFox said:
UPDATE:

All existing MLPs at my primary job site have been replaced along with our CMG changing hands and our "shift map" changing to reflect more physician hours and far less MLP hours.

All of them.

Every single last one.

We have hired two new PAs (no NPs) and the message has been sent to these new hires that: "You're not here to argue; you're here to see low acuity things quickly, not try and pick up 2's and 3's and argue with us about "how you would do it differently".
Click to expand...
Ian.JPG
 
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RustedFox said:
UPDATE:

All existing MLPs at my primary job site have been replaced along with our CMG changing hands and our "shift map" changing to reflect more physician hours and far less MLP hours.

All of them.

Every single last one.

We have hired two new PAs (no NPs) and the message has been sent to these new hires that: "You're not here to argue; you're here to see low acuity things quickly, not try and pick up 2's and 3's and argue with us about "how you would do it differently".
Click to expand...

What where the old and new CMGs?
 
RustedFox said:
UPDATE:

All existing MLPs at my primary job site have been replaced along with our CMG changing hands and our "shift map" changing to reflect more physician hours and far less MLP hours.

All of them.

Every single last one.

We have hired two new PAs (no NPs) and the message has been sent to these new hires that: "You're not here to argue; you're here to see low acuity things quickly, not try and pick up 2's and 3's and argue with us about "how you would do it differently".
Click to expand...
The ****ing smile on my face. Make sure all of your partners bust their ass for a couple months. Make it obvious this system works lol.
 
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TheSingularity said:
TH sucks so much. I hear APP sucks too tho?
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So far, so good with them. We have near total local control of issues relevant to us, have changed the compensation model for the better, and will have a year-end bonus. No fake stock program or any of that nonsense. Light-years better than TH.
 
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You down with APP? (Yeah you know me)
Who's down with APP? (Every last homie!)

Sorry...couldn't resist. Every time I see APP I can't get that Naughty by Nature O.P.P song out of my head from 1991.
 
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bravotwozero said:
Hah, welcome to the family! Our group just merged with them.


Sent from my iPhone using Tapatalk
Click to expand...

Any of you guys in TN? I spoke with them about IC work there and wasn't impressed by the attitudes of some of them.
 
Nope, TX. It’s been business as usual here since the merger with little to no change in our day to day operations.


Sent from my iPhone using Tapatalk
 
Well the thing with APP is that they usually staff HCA hospitals they are their CMG of choice
 
I'm not familiar with all the APP hospitals in TN but I always though the Wellmont system was fine unless things have changed in the past few years. That pre-dates APP's takeover of their EDs though.
 
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Brigade4Radiant said:
Well the thing with APP is that they usually staff HCA hospitals they are their CMG of choice
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Does that mean that they out competed Envision for HCA? Higher level of fee splitting? Even greater levels of unethical behavior? Questions, questions, questions!
 
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