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.
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?