Sunday, August 19, 2012

Listing and Such

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).