From time to time I’ll stumble upon an old chart in my office that goes back 40 years. My predecessors charted office visits on sheets of lined manila card stock, which would suffice for at least 15 to 20 visits. Clearly, these charts were only intended for the physicians as a way to refresh their memory of what happened from one visit to the next. For example, the documentation for one visit read simply, “1/20/67: pharyngitis » penicillin.”
These days chart notes are primarily not for the physician or patient, but for all the others who aren’t in the exam room and yet feel they have a stake in what takes place in this once confidential arena. To satisfy coders and insurers, my documentation for a 99213 sore throat visit must contain one to three elements of the history of present illness, a pertinent review of systems, six to 11 elements of the physical exam, and low-complexity medical decision making. My malpractice carrier and my future defense attorney would also like me to explain my clinical rationale for why the patient has strep throat and not a retropharyngeal abscess or meningitis. A table with a McIsaac score calculating the likelihood that this patient does indeed have strep throat might be nice as well. If I prescribe a weak narcotic for a really nasty case of strep, the state medical board would be pleased if I addressed what other medication has been tried and whether the patient has any history of addiction. I’ll also need to document that I explained the proper use of any medications and the need for follow up if the patient doesn’t get better.
When I’m finally done with my note, it looks like this:
CC: Sore throat x 2d
HPI: 17 y/o F with 2d h/o sore throat. Has an associated headache and fever to 101°. No significant cough. Patient has noticed some swollen lumps in neck. Having significant pain despite use of Tylenol, ibuprofen and salt water gargles.
Social history: No history of substance abuse or addiction.
ROS: Denies neck stiffness or back pain, no rash. No difficulty speaking.
PE: VS: AF, VSS.
Gen: Alert, pleasant female in NAD.
HEENT: NC/AT, PERRLA, EOMI, TM clear b/l, OP notable for tonsillar enlargement with exudates. No asymmetry or uvular deviation present.
Neck: + tender anterior cervical adenopathy, no nuchal rigidity or meningismus.
CV: RRR S1/S2 without murmurs.
Abd: Soft, nondistended, nontender, no hepatosplenomegaly.
McIsaac’s score = 4; Rapid strep: +
A: Streptococcal pharyngitis
P: 1. PenVK 500mg PO TID x 10 days. Discussed risks of medication including allergic reaction and complications of not taking full course of antibiotics including rheumatic fever and valvular heart disease. 2. Hydrocodone elixir QHS to help relieve pain particularly when trying to rest. Has already tried acetaminophen and NSAID and will continue salt water gargles. Follow up if no improvement in one week. Have discussed other potential diagnoses and reviewed warning signs of retropharyngeal abscess and meningitis. Patient agrees and understands plan.
Like I said, “pharyngitis » penicillin.”