Friday, April 24, 2009

Orthopedic EMR Documentation

The orthopedic physical examination: short, sweet and nearly uninterpretable:
Gen: NAD
Incision c/d/i
Motor 5/5 pf/df/ehl
Silt @ t/s/s/sp/dp
DP/PT pulses 2+
One would think they were on Twitter.

-Wes

11 comments:

HugeMD said...

Interesting that these guys had to be relatively smart in med school because (at least when I went) ortho residencies were competitive to get into. What dumbs them down? Too much bone dust to the brain? Maybe inhaling fiberglass fibers from cutting off casts?

Anonymous said...

That's probably the problem...too much time on Twitter.

In all seriousness, does that pass as valid documentation for Joint Commission and State Department of Health requirements? Or is this from a private practice that is not under such scrutiny? Just curious, is all. Thanks.

Anonymous said...

Are there interpretor services between Ortho and English?

DrWes said...

Anony-

Given the number of tests/findings documented - it probably still qualifies, with the interpretation and history, as a "expanded problem-focused evaluation" as part of a established follow-up code, i.e., at least a level 2 visit (E&M code 99212).

-Wes

Anonymous said...

Thanks for answering my question, Dr. Wes. I am a former medical transcriptionist (frustrated with being outsourced) and had not yet encountered the EMR when I chose to leave the field.

The Happy Hospitalist said...

that's hilarious. I'm surprised they did as much as they did.

The Twitter comment was classic

Stockholm said...

I got in touch with the one who wrote that cryptic stuff. His answer was :

"I find your lack of faith disturbing, Dr. Wes."

I also asked him if he suffered from asthma, but he didn't answer... Creepy guy, really.

;)

Keith Sarpolis said...

Wes,

I don't really know which is better; the overwhelming amount of cr*p that I find populating notes and that require a search party to find the impression and plan of the doc, or this brief, cryptic, and to the point note. Actuallly, I find this ortho note the more honest of the two!

Maybe if we were somehow paid on some incident of care basis, instead of this widget type basis that requires creating elaborate notes to justify a higher level of payment, we could all be more to the point and save ourselves all a heck of a lot of time. This ortho note is exactly that since surgical procedures tend to be paid by incident of care with a global payment for the surgery and the post op care out to 30 or 60 days. Thats also why you see ortho docs rarely see there patients post op because they have the residents or their nurse practitionrs handle all the post op care. One of the most common complaints of patients after surgery these days is "what happened to my surgeon? I have'nt seen them since I went under anesthesia!

roger said...

I just had to try and interpret this, but I think I got about 75%. Any help with the rest? I’m a 4th year starting internship in July, and figure I should learn how to read this by now.

General: No apparent distress
Incision site is clean, dry, and intact
Motor exam demonstrates 5/5 strength in plantar flexion, dorsiflexion, and Extensor hallucis longus, (i.e. eversion?)
No idea about this line at all: Silt @ t/s/s/sp/dp
Dorsalis pedis and posterior tibialis pulses are 2+/4 (i.e. normal)

Any help on line 4?

Anonymous said...

Sensation intact to light touch in tibial, saphenous, sural, superficial peroneal, and deep peroneal nerves.

Still better than cut and paste medicine EMR notes

Anonymous said...

cut and paste ortho notes > cut and paste medicine notes? i'm not sure there.