The Medical Record

00:01 So the only person who likes change is usually a baby with a wet diaper.

00:06 The only time not to expect change though is when you’re dealing with a vending machine.

00:10 Everything we do in healthcare can be done differently and will be done differently.

00:15 When I trained, we had paper charts.

00:18 Everything was written freehand.

00:20 We could draw drawings in the medical record to show what our patient looked like or a piece of our patient, or have our patient draw to say what they felt like.

00:31 We guided the chart and we guided how our notes were kept.

00:36 We focused on what we felt was important or our patients felt were important.

00:42 The electronic medical record is a self-populated, directive type of exam.

00:47 So this is much different than the free handed exam in the past in that templates will ask groups of questions and questions that lead the discussion in a certain direction and they lead the discussion towards the most common or most probable etiology of an illness, and that’s how the bundling occurs.

01:08 The problem is, when people go off of that or don’t have something that’s common and we often say that hoof beats come from zebras and horses, so you don’t always look for the zebras.

01:22 You want to have the ability to find them.

01:24 So the examiner can create their own template, but medical students typically can’t.

01:29 You can put different systems in place where you freehand within there and that’s often where people cut and paste which tends to fill the medical record in ways that aren’t ideal.

01:42 Scribes also fill the medical record, but they tend to listen to a provider ask the questions, and then try and backhand it into where it fits.

01:53 So the electronic medical record guides the exam towards the most probable and common causes, but again, hoof beats come from both horses and zebras.

02:03 You want to start from where the patient is and explore around the problem.

02:07 Any question or any issue the patient has should have more questions asked.

02:12 Any positive needs to be pursued.

02:16 So when we do a review of systems, it tends to be a list.

02:19 When we do our exam, we tend to get bullet points where we say any headaches, any nausea or vomiting, or any dizziness. We go down the list— any double vision, blurry vision, or difficulty seeing.

02:29 You have your questions you ask and they become rapid fire.

02:33 What you’re looking for is positives.

02:35 You get a positive, you stop, because when you present— presenting is how you’re thinking, what you’re focusing on— and when you present, that’s how you’re going to be graded, how you’re going to be assessed by your superiors.

02:48 And they want to know if you found abnormals.

02:50 They want to know if you’ve found anything that didn’t fit, anything that’s going to lead you to need further investigation and may need care.

02:59 So the subjective history and review of systems are done by the provider when you explicitly ask if they’ve had something or haven’t had something.

03:10 You also develop your own system.

03:11 How do you deal with 100 different questions? You ask rapid fire.

03:16 Well, if I ask them, they admit or deny.

03:19 If they do it, they state it.

03:22 I’ve got my own system so I know if I had to elicit something or if it’s something that they cared about and they wanted to talk about further.

03:32 So the history, again, subjective.

03:34 Patient complaint in their own words and it’s prompted by the chief complaint— the presenting symptom, and why patient came to get care today.

03:45 So the history starts with the patient’s agenda, and then from the patient’s agenda, we try and expand it.

03:52 The review of systems is a review of systems.

03:55 You go through each system and ask as many questions as you can think of as fast as possible.

04:01 Do you have any headaches, blurry vision, double vision, difficulty seeing, any problems swallowing, any change in taste— it is a neuromusculoskeletal exam looking and focusing on the nervous system and the musculoskeletal system.

04:13 Does anything cause your arms and legs to go numb? Do you drop a coffee cup? Are you having more clumsy movements? Are you having more difficulty functioning? Do you feel awkward cutting your food now where you didn’t before? Any tremors or shaking? Any problems with coordination or balance? And are you thinking as sharply as you did before? Do you rely on your memory like you did before or are there any changes in how you rely on your memory? Do you need reminders? These are all things I look at for the neural system to make sure that they’re thinking okay and their nerves are intact.

04:49 When I get to the musculoskeletal system, I ask about their back, about their spine, about their joints, and is there anything that they used to be able to do that they can’t do now? Do their muscles hurt them? Do they feel like their bones are creaking more or functioning a little bit differently? I care about joint noise.

05:04 I care about what things sound like and look like.

05:08 People complain about this often and I think it’s important to pursue it to see if there’s any relationship.

05:15 We also focus on movement.

05:17 Does it hurt to move? Does it hurt to walk? Can they walk as far as they walked before? Any weakness or difficulty functioning? Any stiffness? And when we get to the 10-step exam, I’ll give you some of my tricks, but we know that at the peak of the life, the most health, the most ability to recuperate, is when people are between 25 and 35 years of age.

05:41 At 35, you get old.

05:43 You can’t heal. You need more sleep. You need more rest. You need more rejuvenation.

05:48 Blood pressure starts to go up 2 points systolic every year, diastolic 1 point every year.

05:52 That happens at 35.

05:54 What’s that got to do with the musculoskeletal system? Your muscles are at their peak between 25 and 35.

06:00 They’re their biggest, their plumpest, and their strongest at that age.

06:04 At 35, we start to see weakness in your non-dominant side.

06:09 The easiest way to test this, is a 30-second stand.

06:12 Whoops. I’ll do the 1 I can do.

06:15 Dominant leg—you should be able to stand on your dominant leg for 30 seconds at 35 years of age.

06:20 Your non-dominant leg, you may go down to 25 to 30.

06:24 So that’s a long test because not everyone has a minute to stand there but it’s fun to look at and it’s fun to evaluate, and it tells you how the person is aging because we know 35 years of age may be the decline, but we also know that by working out, by staying active, and by eating right, you can delay that 15 to 20 years.

06:46 Your blood pressure doesn’t need to go up, your muscle mass doesn’t need to decline, and there are also hormonal effects from the muscles that feedback that determine how much muscle loss you have and where you have it.

06:59 A lot of people focus on the larger muscle, and they look prettier but they don’t help motion as much as the smaller muscles.

07:08 So you need a mix of both.

07:10 So the movement matters.

07:12 Pain matters. Weakness matters. Stiffness matters.

07:15 Spasm and function— and I always ask, any noise, deformities, or asymmetries in your joints? Are there things you can do on your right that you can’t do on your left? Just part of a review of systems that gives you a sense of how somebody is functioning and how they’re feeling and what’s going on with their musculoskeletal system.

07:31 And each person has to develop their own style.

07:34 They have to know what they’re comfortable with.

07:35 Initially, you tend to ask all the questions in sequence.

07:39 As you get more experienced, you can mix the review of systems with the exam.

07:44 It saves time and it makes more sense to the patient when you’re pushing on their ears and examining the ears, that you ask any trouble with hearing? Any trouble with balance? Any trouble with infection? Have you noticed any flaking? We know that ears grow with age, again, starting at 35 years of age expanding at 55 to 60.

08:04 The ears start to grow. They start to grow hair.

08:07 Part of the normal lifestyle.

08:10 It’s good to do that while you’re doing the exam and it makes sense to somebody because otherwise you’re off in left field.

08:16 If you’re asking about earwax—if it’s changed color or consistency out of nowhere, so it makes more sense if you do it during exam but that takes time and practice.

08:25 And again, the electronic medical record is pulling us away from the patient and that’s something that needs to be noted and guarded against.

08:31 You need to separate yourself from the record to do the exam, to touch the patient, and to see what’s going on.

08:39 So quick change of pace because as a practicing physician, we always wonder what gets paid for and what doesn’t, and how does that change what we do and does that dictate what we do? And the truth is, payers do dictate what we do sometimes.

08:57 How many body parts do you examine and how often do you examine them and how complicated s what you’re going to do? So CMS—Medicare and Medicaid services— will determine what’s paid for.

09:12 Private insurance will modify that somewhat and it will determine how many body parts and how extensive your review of systems is.

09:21 If you do a review of systems on one part of the body, it will get you to a certain level.

09:26 If you want to expand your visit to a level 3, 4, or 5, you need to get beyond the nervous system and the musculoskeletal system and examine heart, lungs, and abdomen and go beyond it.

09:40 But to do that, you need to have a link from the musculoskeletal system to say why you’re doing that.

09:46 So that’s part of the holistic exam, and if someone comes in complaining of left shoulder pain, but they’re walking funny or they’re having other issues with sleeping or chest pain, those are things that are going to lead you in other directions.

10:01 And the reward is that if you follow those, you get reimbursed at a higher rate.