CMS is altering notice necessities, amongst different adjustments.  Bob Doherty has an exquisite abstract: “Medicare’s historic proposal to vary the way it pays physicians.”

As all the time, we actually could have a tough time finding out the unintended penalties of those adjustments, however they actually appear to be a transfer within the correct route.  To me crucial change is a give attention to notes: “Permitting medical resolution making to be the idea for documentation, requiring physicians to solely doc modified info for established sufferers and to sign-off on fundamental info documented by apply employees.”

Hopefully, we’ll start to show and count on Larry Weed’s SOAP notes as taught within the early 70s.  Right here is an instance of a completely fictional hospital notice that I might need written in 1975.

#1 Hyperglycemia

S – No complaints.

O – Glucose lowered from a excessive of 800 to 150.  Affected person had 2 hypoglycemic episodes.  Anion hole stays regular (I’d embody the BMP right here).  Regular phosphate.

A – Glucose simply lowered.  Affected person had hyperosmolar nonketotic syndrome.  Potassium and phosphate stay regular.

P – Change from IV insulin to scheduled long-acting insulin and short-acting with meals.  Will reinstitute his prescribed 25 u glargine day by day with 5 u common with every meal.

#2 Confusion

S – Now not confused.

O – Alert and oriented x three.

A – Downside resolved – doubtless secondary to glucose decreasing.

P – Proceed current administration.

#three Low BMI

S – Affected person states that he turned skinny 6 years in the past when diabetes recognized.  He provides a historical past of pancreatitis a minimum of 2 occasions and what appears like a partial Whipple.  He additionally describes steatorrhea for six years.

O – BMI 13

A – Given the historical past of pancreatitis, brittle diabetes and steatorrhea, we suspect that the affected person doesn’t have kind 2 diabetes mellitus, however fairly kind 3c – pancreatic diabetes.  This additionally explains the earlier historical past of metformin not serving to his glucose management.

P – This adjustments our targets – we aren’t in search of tight management.  We are going to begin pancreatic enzymes as this would possibly assist his steatorrhea.

What do you consider this model notice?  I used to be skilled to write down notes like this.  They’re problem-oriented and reveal our thought course of.  I can solely hope we return to this model.

Robert Centor is an inner drugs doctor who blogs at DB’s Medical Rants.

Picture credit score: Shutterstock.com




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