The hospitals I cover have all made the transition to electronic medical record (EMR) documentation. This means all our daily progress notes and H&P's have to be done using the templates in the EMR. I'm fairly computer literate so the transition hasn't been awful. I actually like being able to read the thoughts and recommendations of other physicians following my patients.
The problem is my unease with some of the drop-down options for "physical exam findings". When you click on "Cardiac", for example, a list of objective findings appears that you can choose to include in your note. These findings include things like "S1 S2 normal, no murmurs, no rubs, no gallops, PMI location," etc. I'll be honest--- I don't think I could reliably tell you what a rub or a gallop is. What I can do is listen to heartsounds and determine if there is an arrhythmia or a murmur (in vague, nonspecific terms). Beyond that, I am sort of flailing to describe what the hell I hear. So most of the time I just opt for the blank option and manually type in my PE findings. It's disconcerting using terminology outside one's comfort level. It's sort of like a neophyte awkwardly trying to describe a wine to a connoisseur---this Pinot has a bold mahogany uplift with a sweet hint of, um, rosemary lingering on the palate, like a faint evocation of a youth spent in Tuscany reading Cicero...blah blah blah...pretentious vomit...
What we need is a set of drop down descriptions that more accurately describe what specialists/non cardiologists are hearing during a physical exam. For example:
General Surgeon- Heart sounds successfully identified. They seem sort of normal.
Orthopod- Dude, I don't even have a heart-listener thingy. Are you kidding me? What am I supposed to do, stick my earlobe on the old guy's sweaty chest? Please consult internist for heart sound evaluation.
Neurologist- I can accurately and easily reproduce what I am hearing by rapping reflex hammer on patient's sternum
OB/Gyne- Oh my god, I don't hear anything at all. Oh wait, maybe I do. Yes! It's soooo exciting.
PM&R- Unable to assess. By the time I got to cardiac exam, it was 3 o'clock and time for my pilates class. Will attempt to listen to chest day after tomorrow.
Dermatologist- Patient has skin over area where I was taught to identify heart beats. Skin appears to have rash. Special cream ordered.
ICU nurse studying to get into CRNA program- PMI identified in 5th intercostal space in mid clavicular line. S1 S2 normal. A grade 3/6 decrescendo murmur is heard best at the second intercostal space and radiates to the neck. A third heart sound is arguably present at the cardiac apex. No rubs or gallops appreciated. Stupid doctors.....