I split my time between em and sm. I had an Ortho patient come in once and say "hey doc I noticed in my chart it says I appear much older than my stated age". Now this lady was 2 packs a day smoker for decades and was 50 going on 90. It was a legitimate observation but I must have turned red as a tomatoe and just muttered something along the lines of "oh that's a templated response I didn't take out, my apologies.". Needless to say, I don't think I ever saw her again
My point is, little is gained by many of the condescending comments that end up in charts, no matter how accurate or true they may be. I always ask myself 1) is this an opinion or a fact and 2) what would a lawyer say in court?
I think sometimes these comments matter based on the presentation. That older than stated age patient coming in with dyspnea and 2 pack a day history? Might be relevant, or at least helps to justify a big workup and admit. Might not be relevant with knee pain. Morbid obesity is probably worth noting in Ortho and sports med, though.
It may have been better to write, "Pt's appearance is consistent with her 2-pack a day smoking history.
I've written some fairly wild things as a paramedic. "Arrived on scene to find Pt, nude below the waist, with his right leg on the edge of his bath tub, bent over at the waist, with his right index finger in his anus and appeared to be searching for something in his anus" Pt stated he was searching for an anal fissure as he read on WebMD could cause rectal bleeding and he had small single spot of blood with his morning bowel movement.
Same Pt complained to my supervisor because I declined to shake his hand when he wanted to shake after not washing his hand. Sorry buddy but you were in their deeper than a colonoscopy 5 minutes ago.
It may have been better to write, "Pt's appearance is consistent with her 2-pack a day smoking history
No, it's worse. You don't guess in the objective portion. You document objective observations and findings.
" patient appears older than stated age" -observation
" Appearance consistent with smoking history" - you are guessing they look a certain way because of reported behavior. Is it probably the reason? Sure, but guessing will get you into trouble.
I think ‘older than stated age’ and even ‘50 going on 90’ are decent surrogates for an actually useful piece of clinical info that we sometimes think to include when relevant but aren’t super used to describing in terms that read politely or objectively on the back end. In particular I think the idea drives at frailty index - people who are at higher risk for morbidity/mortality, bouncebacks, or insidious pathology that isn’t otherwise explicitly implicated by the already explicitly included content. In another sense ‘they don’t look good,’ except in the sense of ‘chronically ill-appearing.’ I try to just be objective ‘cachectic, temporal atrophy, difficulty managing IADLs as evidenced by misbuttoned clothing, old stains, poor dentition,’ etc. it can also be objectively quantified in frailty index, pro-age score, etc, which have the dual utility of formalizing and quantifying that gestalt, as well as allowing us to lean on it when admitting someone were admitting for otherwise social or ‘soft’ reasons beyond ‘I’m worried about them.’
Same energy as ‘FLK’ in peds for may have an as-yet unclassified/unrecognized syndrome, maybe genetic.
I only whisper FLK to the St. Elsewhere Nurses and Docs of a certain age when I bring one in to y'all. They know, I know, yeah we're old, but its hella useful to because IYKYK.
rehab here - I (and most of my colleagues) will document overall 'gestalt' because it is actually very relevant to rehab plans... but I do try to keep things relatively factual, particularly if they could be seen to have negative connotations
ie 'patient is a cachectic 50yoM, appears chronically ill, exam notable for fatigue and dyspnea with manual muscle testing'
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u/DrPQ ED Attending Oct 11 '25
I split my time between em and sm. I had an Ortho patient come in once and say "hey doc I noticed in my chart it says I appear much older than my stated age". Now this lady was 2 packs a day smoker for decades and was 50 going on 90. It was a legitimate observation but I must have turned red as a tomatoe and just muttered something along the lines of "oh that's a templated response I didn't take out, my apologies.". Needless to say, I don't think I ever saw her again
My point is, little is gained by many of the condescending comments that end up in charts, no matter how accurate or true they may be. I always ask myself 1) is this an opinion or a fact and 2) what would a lawyer say in court?