Then and Now (the paper medical chart v the Electronic Medical Record)

BEFORE THE EMR AND BEFORE JCAHO AND BEFORE THE MALPRACTICE LOTTERY, HERE IS A PERFECTLY ACCEPTABLE PHYSICIAN'S ENCOUNTER NOTE...

DATE ETC...

SUBJECTIVE: NECK PAIN IN A 20'ish YEAR OLD MALE. NO DISCRETE INJURY. GRADUALLY WORSE OVER PAST FEW DAYS. NO FEVER OR HEADACHE. PT BELIEVES HE TWISTED IT IN FLAG FOOTBALL GAME. NO RADICULAR OR MENINGEAL SX. PAIN IN TRAPEZIUS WITH ROTATION OF NECK TO RIGHT AND WITH FULL NECK EXTENSION.
OBJECTIVE: WDWN SM NAD AXOX3 VS NL
LIMITED ROTATION OF NECK DUE TO PAIN IN CAUDAL ASPECT OF TRAPEZIUS. NO MIDLINE C SPINE TENDERNESS.EQUAL STRENGTH UPPER EXTREMITIES BILATERALLY.
ASSESSMENT: NECK STRAIN
PLAN: NSAIDS AND FLEXERIL AND LIMIT ACTIVITY BASED ON PAIN. RETURN FOR FOLLOW UP IF NOT BETTER IN A WEEK. RETURN SOONER IF WORSE OR FOR FEVER/ VOMITING/ HEADACHE WITH NECK PAIN. PATIENT VERBALIZES UNDERSTANDING OF INSTRUCTIONS AND DIAGNOSIS.

THE END

ME

MEDICINE BY COMPUTER IN 2010... YES, THE BELOW 'CHART' IS REALLY ON THE SAME PATIENT, YES, THE ABOVE IS WHAT I INPUT, AND YES, ALL THE BELOW WAS SPIT OUT... YES, I'M TELLING YOU... PLEASE MAKE IT STOP (absence of exclamation point emphasizing fatigue and hopelessness).

Patient: Mouse, Mickey J
Date: Day After Yestermorning
Appt Type: Walk-in
Treatment Facility: Clinic
Patient Status: Outpatient
Reason for Appointment:  neck pain
Appointment Comments: xxx Refreshed by doctor Doctor @ 3456 GMT 1776
Problems
 Chronic:
 • Visit for: ears/hearing exam following abnormal hearing screening
 • Visit for physical exam
 • The patient was overweight
 • Patient education about a proper diet
 • Tobacco use
 • Visit for: health exam of defined subpopulation
 • Psychiatric diagnosis or condition deferred on axis 29
 • Insomnia
 • Common cold
 • Visit for: occupational health/fitness exam
 • Counseling for an individual patient about medical management
 • Fluid and electrolyte disorders
 • Visit for medication refill
 • Special symptoms or syndromes, not elsewhere classified
 • Pneumonia
 • Tonsillitis

 Family History
• No Family History of genetic disease
• No Family History of early deaths
• No Family History of heart disease
• No Family History of cancer
• Hypertension   (Father)
• Skin cancer   (Paternal-Grand Mother)
• Diabetes mellitus   (Paternal-Grandfather)
• Family medical history
 

 Allergies
• AMOXICILLIN (AMOXICILLIN TRIHYDRATE): Anaphylaxis (allergy test at birth)
• Red Dye

Active Medications
Active Medications
Status
Sig
Refills Left
Last Filled
XXX 10 mg Tab complete PO #1 RF0
NR

Vitals
Vitals Written by MEDTECH @ 35th August 1863
 BP: 138/88, HR: 72, RR: 14, T: 98 °F, HT: 69 in, WT: 225 lbs, BMI: 33.23, BSA: 2.172 square meters, Tobacco Use: Yes,
What type of tobacco product? smoke, Amount of tobacco product used per day: 3/4 pk a day, Would you like to quit? No, Alcohol Use: No,
Pain Scale: 2/10 Mild, Pain Scale Comments: neck

Questionnaire AutoCited by Doctor MD @ 3345 etc...
Questionnaires

Depression / Suicide Screening questionnaire On: THIS VERY DAY
  1. Over the past 2 weeks, have you been bothered by any of the following problems?: None
  2. Have you had any experience that was so frightening, horrible, or upsetting that IN THE PAST MONTH, you: None
  3. Over the past 2 weeks, have you been bothered by any of the following problems?: None
  4. Have you had any experience that was so frightening, horrible, or upsetting that IN THE PAST MONTH, you: None

PREVENTIVE MEDICINE SCREENING
  1. Do you have an illness or injury or upcoming surgery which will reduce your level of excercise a lot: No
  2. Did you have to lose weight to join the BORDER COAST GUARD PATROL NAVY?: No
  3. Have you ever exceeded the body fat standard OF THE BCGPN: Yes
  4. Do you struggle to avoid exceeding the body fat standard or are you currently gaining unwanted weight?: Yes
  5. Do you have a sedentary job (sit a lot during the day)?: No
  6. Do you eat out 3 or more times per week (fast food, take-out, delivery, or restaurants)?: No
  7. Enter the number of containers you drink per day, DO NOT include 'diet' beverages (less than 10 calories per serving) of ~150 kcal - 12 oz can of soda or beer; 1-5 oz glass wine; 1.5 oz liquor: 1
  8. ~240 kcal - 20 oz bottle of soda  (do not include diet): 0
  9. ~160 kcal - 16 oz bottle of any fruit juice (or 16 oz total over the day): 0
  10. ~160 kcal - 16 oz bottle of sport drinks: 1
  11. ~240 kcal - 1 quart bottle of sport drinks: 0
  12. ~200 kcal - 20 oz sport drinks: 1
  13. ~150 kcal - 12 oz specialty coffee drinks: 0
  14. Based on the above answers, do you drink over 500 calories per day of sweetened beverages?: No
SO Note Written by MEDTECHPERSON JUST NOW TODAY
Chief complaint
The Chief Complaint is: Neck pain.
History of present illness
 The Patient is a 1 year old male.
PT reporting with neck pain. Pt says that his pain is on the back right side of his neck. He says it hurts whe he looks up and when he looks goofy though he is hard to understand since he is only one.
 In the BPCGN and currently working.  Visit is not employment related or other stuff like that.
Allergies
Allergy information was reviewed and verified with patient.
Current medication
Current medications reviewed and reconciled.
.
Past medical/surgical history
Reported History:
Medical: Reported medical history: Reviewed
.  No previous hospitalizations  that are associated with the reason for this encounter:, no previous emergency room visit  that are associated with the reason for this encounter:, and no history of cancer.
Surgical / procedural: Surgical / procedural history: Reviewed
.
Reported medications: Not taking OTC medications, no dietary supplements, and no vitamin supplements.
Reported prior tests: No prior tests were performed  at non-MHS facility that relate to this encounter includes:
Physical findings
Neurological:
° No learning disability was noted (barriers to learning).
Therapy
 • Immunization administration: up to date.
 • No herbal medicines.
Counseling/Education
Patient verbalized understanding and accepted instructions.

SO Note Written by ME DOCTOR ABOUT TEN MINUTES AGO
History of present illness
 The Patient is a 1 year old male.
 He reported: Encounter Background Information: l LATERAL NECK PAIN ABSENT DISCRETE INJURY. PAIN IN TRAPEZIUS WITH ROTATION OF NECK TO RIGHT AND WITH FULL NECK EXTENSION. NO RADICICULAR SX.
Objective
WDWN SM NAD AXOX3 VS NL
LIMITED ROTATION OF NECK DUE TO PAIN IN CAUDAL ASPECT OF TRAPEZIUS
EQUAL STRENGTH UPPER EXTREMITIES BILATERALLY.


A/P Written by DRX AT A FUTURE DATE
1. NECK STRAIN
 Medication(s): 
-NAPROXEN (NAPROSYN)

-CYCLOBENZAPRINE)--PO 10MG TAB - T1 TAB PO QHS PRN #30 RF0 Qt: 30 Rf: 0
2. visit for: screening exam
Disposition Written by DRX YET!
Released Work Limitations
Follow up: as needed with PCM. - Comments: MAY PERFORM EXCERCISE PROGRAMS AS DICTATED TO BE LIMITED BY PT PAIN.Discussed: Diagnosis, Medication(s)/Treatment(s), Alternatives, Potential Side Effects with Patient who indicated understanding. - Comments: RECONCILIATION OF MEDICATION LIST PERFORMED, HONEST, I SWEAR JCAHO!


Signed By  DOCTOR ME TODAY JUST NOW