Tuesday, May 10, 2016

How To Read Your Electronic Medical Record Chart Notes


I am Not an SOB! How DARE YOU!

Many Patient Portals are now allowing patients to see the progress notes that physicians write.  This can be a confusing and frustrating experience for patients. 

     One of the problems I have seen is patients taking offense at the medical terminology, thinking physicians are making a personal judgement, instead of writing objective terminology.  

     Let me explain.

     Physician's notes are generally written in the SOAP method:  

                         Subjective, Objective, Assessment and Plan.

     Subjective:  This section describes the patient's complaints. "Complaints" does not mean what it does in normal language. "Complaints" are what the patient is "complaining of" or suffering with, or what brought the patient in to begin with. Why is the patient here? 

     Part of the HPI or History of Present Illness, is the Chief Complaint.  This is the reason for the visit that the patient tells the medical assistant.  It may not be the "real" reason the patient is there, as often, patients feel uncomfortable telling a medical assistant why they are really there. 

     In the HPI, doctors use a lot of standardized abbreviations which may be misconstrued by patients, or just plain not understood at all. 

     For example, "The patient is SOB" does not mean, "the patient IS an SOB", but that the patient is "short of breath."  

     Often we use quotation marks to state exactly what a patient has told us, and then we elaborate with the Review of Systems(ROS).  

     The ROS is a litany of questions we ask to try to ascertain any other associated symptoms going along with the chief or main complaint. We generally start with weight loss or gain, rashes, sleep problems, and work our way down from the head to the toes. This litany can change based on the chief complaint. 

If it is clear the patient is suffering from a cold, we aren't going to ask about toe fungus in the ROS. 

     We also have to use very standardized, objective language. Some of this can be misconstrued as insults as read by patients, but is medically objective language. The biggest one is "obesity."  Obesity is a BMI of 30 or higher.  A BMI of ≥ 35 or 40–44.9 or 49.9 is morbid obesity. A BMI of ≥ 45 or 50 is also known as super obese.

     When doctors use these terms, they are not making a personal slur, or insult. It is a medical term. 

     Some other terms often used in the history/ROS are, 
     CP=Chest pain, 
     GERD=Gastroesophageal reflux (heartburn)
     melena=black, tarry, sticky stool indicative of an upper gastrointestinal bleed 
          (UGI bleed) as in a bleeding ulcer.
     hematochezia/BRBPR=bright red blood per rectum-which means what it says. 
          It is often from a bleeding source in the large intestine/colon
     GI=gastrointestinal (any section of the gut, from the esophagus to the rectum)
     GU=genitourinary (anything in the genital area or urinary tract)
     Neuro=neurologic symptoms/signs

The next section is OBJECTIVE: the PHYSICAL EXAM.

     Here again, there are many abbreviations.

     Generally the Physical Exam starts with the Vital Signs(VS):

  BP (blood pressure), HR (heart rate), T (Temperature), O2 sat(Oxygen saturations, expressed in percentages), Weight, Height, often in centimeters and kilograms. This is not to obsurate.  This is the international standard. We use metric often in medicine. 

     Then comes the BMI (Body Mass Index).

     BMI is a person's weight in kilograms (kg) divided by his or her height in meters squared. The National Institutes of Health (NIH) now defines normal weight, overweight, and obesity according to BMI rather than the traditional height/weight charts.

    The BMI is not always an accurate indication of the patient's fitness. For example, I have seen people with BMI's over 30, and not an ounce of fat on them because they were body builders. They were all muscle. 

     Next is the physical examination. 
     We start at the top and work our way down usually. Depending on the age of the patient, the physical exam may be different, but generally for teenagers and up, it is fairly standard. There may be some differences in the very elderly, where we look at things like their ability to get up out of a chair or walk. 

     Some standard abbreviations: 

PE=physical examination
HEENT=Head, Eyes, Ears, Nose, Throat
     PERRLA=Pupils Equal Round and Reactive to Light and Accommodation-
            When we shine the light in your eyes we are looking for pupillary reactions 
     EOMI=Extraocular Eye Movements Intact. This means your eye muscles are all 
            working normally
     Pharynx:  Your mouth and throat. We describe whether it is moist, red, whether 
           the tonsils are there and inflamed, whether you have post nasal drip. What 
           your teeth and gums are like. Are there sores in your mouth/gums. Bad breath?
     EAC and TM's=External Ear Canals and Tympanic membranes-your ear canal and eardrums. We describe what they look like, whether they are blocked with 
           ear wax (cerumen), and whether the "landmarks" or the normal things we see on
           eardrum look normal. 
     Nares=your nostrils. We describe the inside of your nose and whether it's swollen, 
           whether you have a deviated septum, ulcers, polyps or growths, etc. 

Neck=Here we describe the lymph nodes and whether they are enlarged. we describe 
     them based on location in the neck. We describe the thyroid (TMG) Thyromegaly-
     is the thyroid enlarged and are there nodules on it?

     Carotid arteries=not always discussed. Are there normal pulsations/sounds?

Pulm (Pulmonary)/Lungs:  
     CTA&P=Clear to auscultation (listening with the stethoscope-no abnormal noises) 
            and percussion-no abnormal sounds when we thump on your back.
     Rales/Crackles=sounds like hair being rubbed next to your ear, or like velcro being 
           pulled apart, heard when listening with the stethoscope. Can mean many 
           different things, from pneumonia, to scar tissue, to fluid in the lungs. 
     Rubs=a sound like grating or squeaking. It can mean there is a problem with the 
           pleura of the lungs, or outer coatings of the lungs. 

     RRR-Regular Rate and Rhythm
     Irreg RR-Irregular Rate and rhythm.
     Regularly irreg rhythm-just that. 
     S1, S2 normal-normal heart sounds of the opening and closing of the heart valves.
     S3 /S4- these are abnormal heart sounds which can be from heart failure, or a stiff
           heart or other causes
     No m/r/g-No murmurs, rubs or gallops. This means no heart murmurs, no heart rubs
           and no abnormal S3 or S4 sounds. 
     Murmurs are often graded from I-VI/VI in intensity and by location. 
           You many see: II/VI SEM ULSB nonradiating. This means, a 2 out of 6 murmur 
           heard in systole (part of the heart cycle) at the Upper Left Sternal Border. It is 
           not heard in other parts of the chest/neck/underarm (not radiating to those parts)

Breasts: We will describe any masses, discharge from the nipple, or lymph nodes. 
     We describe the breast in quadrants:  RUOQ, RUIQ, RLOQ, RLIQ are: 

          Right Upper Outer Quadrant, Right Upper Inner Quadrant, Right Lower Outer 
          Quadrant, and Right Lower Inner Quadrant. 

     NABS=Normal Active Bowel Sounds
     No HSM=No Hepatosplenomegaly-this means the liver and spleen are not enlarged
           Sometimes if the liver is enlarged, it is described in centimeters in the chart 
     No masses-means that the physician does not feel any masses. It doesn't mean 
            there aren't any masses, just that he/she cannot feel any.
     No rebound tenderness/no rebound- means when there is pain pressing down, it 
             is not worse when you let go of the pressure. This can be a sign of 
             inflammation of the lining of the abdominal cavity, if there is rebound. 

GU: Depending on the sex of the patient, the explanations vary, obviously. 
     Normal external (male/female) genitalia=self explanatory
     no adnexal masses (female)-on the internal pelvic exam done with the hands, the 
           examiner is unable to feel anything abnormal.  This can be "limited by body 
          habitus" which means the patient's adipose or fatty tissue, or strong abdominal
          muscles can make it difficult to actually feel anything.

This is not a complete list, obviously. There is the neurologic examination, musculoskeletal exam, etc. 

The NEXT section is DATA: 
     This is part of the OBJECTIVE section, and includes, labs, xrays, and other test results


     This is the section where the patient's "Problems" are delineated and discussed and the possibilities of diagnoses are discussed, and a plan for evaluation and management is put together. 

 PROBLEMS: These are now described through the ICD-10 coding system. 

     Within the healthcare industry, providers, coders, IT professionals, insurance carriers, government agencies and others use ICD codes to properly note diseases on health records, track epidemiological trends, and assist in medical reimbursement decisions.
     ICD-10 is frustrating because there are very specific ways to describe medical issues and there is not always a diagnosis code that perfectly pertains, so one needs to pick the BEST OPTION. 
     Also, a patient may come in with what sounds like panic disorder or anxiety. The doctor may be fairly certain this is what is going on. He/she puts in the diagnosis code of "Anxiety disorder." The patient sees this and is upset. They came in with heart racing and palpitations, and SOB (shortness of breath) and tingling in their fingers and around their mouths and are worried they will die. If the doctor doesn't explain that he/she is fairly certain this is anxiety, but is testing/evaluating for other causes also, the patient may be surprised to see this diagnosis code. 

     As a patient, one needs to understand that putting in 5 different diagnosis codes that can be summarized in a single fairly certain diagnosis code, makes the most sense and is what is required. The insurers and government want the MOST SPECIFIC DIAGNOSIS CODE.

     Also We can only put 4-6 diagnosis codes on a single "bill" to the insurance company, and if you came in with anxiety symptoms but also had something else, like a UTI, if we use: Dyspnea (shortness of breath), Palpitations, numbness, chest pain, and dizziness-all of which could be summarized under "Anxiety/Panic" attack, then we can't put the UTI diagnosis code. 

     We also order tests through the Electronic record, and these show up under the "PLAN" section of the note. You will see lab abbreviations, consult/referral recommendations, test orders like CT or ultrasounds there. 

I hope this helps a little. See my disclaimer though.

     ***This is a brief explanation. Please understand none of this is meant to be medical advice. If you have questions about your medical record, address them to your physician. I will not be answering any specific questions about your personal medical record. 

May 10, 2016


No comments:

Post a Comment