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[quote=Anonymous][quote=Anonymous][quote=Anonymous]Doc here- first of all, yes, if you don’t click with her and don’t trust that she does her job well then absolutely shop around. It’s your health and your life!

Second of all, when I document, there is an option for a template for almost every kind of encounter. If a kid has strep throat I click the template , add some details, delete some others, and lock the encounter. Otherwise I’d be documenting for 6 hours every evening after I left work. So yeah I’m sure a lot of those charts say I educated the family on a million types of infection control when I didn’t (although technically, legally, I did, by handing them the discharge paper that includes a million infection control suggestions). Does that make me a bad doctor? That’s up to you. I’m just trying to see patients and practice solid medicine, I’m not trying to write a novel for every standard patient encounter just so insurance companies will grudgingly agree to pay for your visit. But some people wouldn’t like that the chart is clearly sort of standardized, and that’s fine, my feelings aren’t hurt.  [/quote]

It's not about hurting your feelings or not.  You should come up with a new shortcut if the shortcut you're using ends up putting false information into people's charts.  For one thing, your causing people to lose valid disability claims with your practice.  I have doctors who include a "review of systems" at the end of the encounter note but didn't actually ask me about any of those symptoms.  I write them back and note that they didn't ask, and if they had, my answers would have been xyz, and I ask them to correct it.  [/quote]

As I said, nothing is actually false- I hand you a discharge summary that has about a page and a half of information about strep throat in kids, anticipatory guidance, reasons to seek further care, etc etc.  And legally, if your doc says "okay so- sore throat, some nausea, fever of 101- no other significant symptoms today? No rashes, diarrhea, headaches, coughing, congestion with this illness?" and the patient says "no", then that's a review of symptoms. If you want your doc to do a head to toe detailed review of systems and a head to toe complete physical exam for (in my example) a visit for strep throat, then you need to find a concierge doc.  With what insurance reimbursement rates are, there is a zero percent chance any doctor who takes insurance is able to do this and not go bankrupt within the year. They couldn't get through more than 12 patients a day. [/quote]

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