Just one more reason why the fun and creativity is sucked right out the job: I am no longer allowed to number medical complaints what with the new-fangled eeeeelectronic medical records keeping system and all. For some inexplicable reason any triage complaint chosen from a pre-loaded list gets immediately coded. We are discouraged from adding multiple complaints because it opens up a couple of cans of worms. In the past, I would simply do this for multiple frivolous complaints:
1. Man-cold
2. Rash x 3 years
3. Requests psych med/pain med refill
4. Work excuse
5. Ingrown toenail
Succinct. Easy to read. Says, "I'm listening, but not very hard right now", and says a lot about the patient without really having to say anything, right?
So now I could just put it all in a free-text stream. It doesn't look as eye-catching when I write:
Pt. states: Cold, rash x 3 years, wants medication refill, a work excuse and an ingrown toenail.
See? Just not as effective.
Along with a litany of complaints that I am now no longer allowed to number was a female, age 30, with:
Facial pain. Low back pain. Knee pain. Constipated. "Feeling weird". "Feeling warm" (not febrile). Peeing less.
She did have a number of medications for anxiety, chronic shoulder pain and fibromyalgia.
Except she pronounced it Fiber Mal-Eye-Ja.
Really. Yes, she was a native English speaking individual. She also mispronounced Klonopin (Klonda-keen), Gabapentin (Gabro-my-pentathol), Lorazepam (Lora-pm).
