Acculturation to Medicine and Clinical Informatics
Abbreviations/Medical-Speak
In Notes, General DocSpeak
| Term | Meaning |
|---|---|
| 2/2 | "Secondary to" |
| CTA | Clear To Auscultation |
| b/l | bilateral |
| NT | not tender |
| ND | not distended |
| SOAP | Subjective, Objective, Assessment, Plan. This is the structure that they use to exchange nformation. Residents -> Attending. |
| EGD/US | Oesophagoduodunem (duo: first part of SI), UltraSound. |
| Claudication | pain with ambulation. |
| HPI | History of Present Illness. |
Latin/Greek Roots
| Term | Meaning/Root/Whatever |
|---|---|
| a | anti/negation |
| diaphoretic | sweaty |
| dys | difficulty |
| ectomy | removal |
| febrile | feverish |
| itis | inflammation |
| ostomy | ? |
| pathy | disease of |
| pne | lungs |
| tachy | fast |
Session 1
Internship is first year of residency.
Residency is same for MD or DO. PGY1,2,3
Chief Residency, usually the best resident, strengthens your fellowship application. Very voluntary.
Fellowship! PGY4
It's a giant hierarchy.
80% of diagnoses juts come from talking to a patient!
H&P Exam
EPIC allows you to autocomplete and do smart phrases.
If neck cannot move up and down, sign of meningitis.
Lymph NOdes Palpation -> Strep infection.
Rales: crackly sounds could be pneumonia.
Session 2
Being 'Healthy' and being in a USOH are two different things!
History
SocialHx is not collected well. You can be bullied at school and present with stomach ache.
You're SUPPOSED to do the Hx, FamilyHx, SocialHx, and ROS but it's not done! It's supposed to be done for the first visit. The initial note is called the HNP (History-n-Physical). Then there's a SOAP (Subj/Obj/Assessment/Plan) note.
Physical
Rigidity of the neck may indicate meningitis.
Wheezing -> Asthma.
Rales -> Pneumonia.
- Clubbed nails usually indicate a chronic heart or lunh condition.
- Pitting edema -> Kidney (check creatinine), Heart (check ultrasound), low Albumin.
Session 3 - HIPAA and EPIC
OR and surgeon and his fellow came in wearing funny shoes and took picture of them oblivious to the presence of a naked patient behind. Another is elevator talk.
18 things in HIPAA.
Doximity is one thing that is used to communicate with patient.
DAGS Copilot. Trying to transcribe notes in EPIC but picked up convo in background about different patient and their notes ended up here.
Note: you're totally allowed to print out your chart and show it to your doctor friend. They cannot access your chart willy-nilly (i.e. without your explicit. consent).
"PHI is worth 100x more than credit card details on the Dark Web"
COWS = Computers on Wheels. Stopped using this term since patients thought "Cows" referred to them! "Wows" is OK.
EPIC: Distinction between clinic visit and CC?
Notes: can be for future self of doctor. can be for billing or substantial event. You gather them through several lenses! Billing, information, regulatory are a few. If you didn't write it down it didn't happen. Notes were much shorter before EHR.
There is something to be said about the act of writing a note as an act of thinking. Contrast with passive listening via an AI.
TODO: Why are outpatient and inpatient notes so different?
Views are very different across clinic and ER. But everything is customizable in EPIC (this is a good and bad thing). Notes apply everywhere.
Notes: you can copy the note forward.
Another cool thing is you can copy the note tempalte. If you want to find out a lot about what other doctors prioritize or how they think, you can explore their note templates (downside is the act of writing a note is thinking so...)
Continuity of care via information exchange and interop is more the exception than the rule.
In addition to notes, there's medication orders, etc that you can use too.
PMH past medical history
GT feeding tube
Session 4
BCX blood culture
SOAP "Subjective": Summary of events that happened overnight. History before today. You color the data with the story here. But when you start today, no story. That's the Objective part!
"Assessment" is a one-liner.
Kids you need to know exact weights because dosage is relative mg/kg and so on.
RVU (Relative Value Unit) salary system comes from CMS. Points-based (decided by Medicare) and how you bill. You have a minimum and then if you exceed some threahold you get a bonus. I don't think this is a nice system but what else would you do?
If you discharge a patient and they come back within 30 days you don't get paid for the first visit. Medicaid is for older people but you can qualify under certain conditions.
Dr had notes pending from September. There's a LOT of burden here. There is no incentive for a note to be accurate; just that it's done. So don't assume that doctors are fastidious with writing them! It's not built into their schedules as a thing. Which is more important, doing it or writing about it (if you had to pick)? Chronic cases may be okay being underdocumented. Simple cases do get documented.
You cannot document every single detail. So what do you note? Note relevance is determined by the person making the note. Note that the patient can see everything on their chart. E.g. kid's mom got deported. Not in note. But dad is unable to make visits out of fear; Social Services called; on note. It all depends.
Billing used to mandate a 10-point ROS but not anymore.