The Chief Complaint
In the introduction to yesterday's blog entry on the popular Kevin MD blog it was noted that physicians are trained to write the chief complaint in quotations so it is phrased in the patient's own words. Coincidentally, this was exactly the topic I planned on blogging about today. Over the years, I have read thousands of medical reports from physicians from all sorts of specialties. For those who list a chief complaint section in the report, many use the quotation system noted by Dr. Kevin. Unfortunately, there have been many times where I have read these quotes and just shook my head because of what was written. Here are some examples of what I have seen, starting with my favorite.
Chief complaint: "Uh."
Chief complaint: "I don't know."
Chief compliant: "Hi, I'm John."
These three separate examples tell me absolutely NOTHING! Well, ok, it tells me tat when the physician walked in the room and said "So, Mr. Jones, what seems to be the problem today?" that the person responded "Uh." But so what?. The body of the report would obviously contain reasons about why the patient came in but that is beside the point. The chief complaint section is designed as a way to convey what is most distressing to the patient. If you are not going to put something in that section that conveys this, it is best to just leave the section blank. When I interview patients, I ask them "What are the three main symptoms that bother you the most at this time in your life. It could be a physical symptom such as a headache, an emotional symptom such as depression, or a cognitive symptom such as a memory problem." I ask them to rank these symptoms in terms of which causes the most distress, the second most distress, and the third most distress. Once you have obtained that information, you are conveying real information and helping you and your readers better understand the patient. Now that's something worth putting in quotes.
posted by MedFriendly | 7:32 PM
4 Comments:
I would think that would be obvious. Why do you think it is done this way by the people doing the first assessment?
Were these hand written CCs or transcribed notes? If you have ever dictated and then read your notes, you will notice a significant amount of errors - depending on the transcription service. Many transcribed notes are entertaining to read... as the person who dictated the note.
These were transcribed and finalized notes. I believe they truly reflected what the doctor wanted in that section. That being said, I agree that there are tanscription errors and too often, people are not reading their notes and catching it. Please see my entry on Proofread your dictations!
At our children's hospital, our nurses are also (apparently) required to note the person who relayed the complaint, if the child does not give his own history. Unfortunately, they have a habit of putting this FIRST in our computer system, which has limited characters, often resulting in CCs like "Per mom, baby has a " or "Per dad, cut on right ", rendering our electronic board completely useless. I've only asked a hundred times to please put the relevant part first, but no dice.
Post a Comment
<< Home