Original is a PDF file....
One hour of paperwork for every hour you spend seeing a patient. And as I have written earlier, that not only takes away from patient time, but recording non important data buries the real data in a pile of trivia...yes, once in awhile you can dig and find that something was recorded but missed...like CSI...or by an aggressive lawyer seeking to sue. BUt maybe it wouldn't have been missed if the doc sat sipping coffee after seeing the patient...time when often you get a "eureka" moment...alas, now we sip coffee while writing "PERRLA...Fundus normal..nasal mucosa pink" on a patient you are seeing for ulcer pain. But what you need to see is if they are pink (did their ulcer bleed?) if the fundus showed signs of high blood pressure, if they had petechiae etc...
And that assumes what is written is correct...I once saw a patient with a massive stroke...the fundus exam showed high blood pressure changes in the right eye, and an artificial eye on the left...when I asked the patient, she nodded yes, she had lost that eye...but the resident, who was a snot and who had massive elaborate notes, had a "normal" exam of the eyes recorded...he hadn't checked the eyes because stroke patients were a pain to care for--you can't "do" anything to cure them, while many patients needed immediate care...
Maybe if he wasn't so busy worrying his notes were sufficient, he would have "seen" the patient instead of just writing up what was required...
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