Saturday, July 10, 2010

EMR


One of the most valuable tools of electronic medical records his being able to review a patients previous visits quickly. I saved this note from residency b/c it was so funny. It had to be written by an off service resident, b/c there is no way an ER resident would write in such detail (hence all my short hand). Anyway, the resident does a great job of painting a picture of this glorious patient.

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HPI: 48 yo WF with past med history of extensive alcohol and drug abuse, bipolar disorder, Hepatitis C cirrhosis, and hypertension who presents after being found down at the bus stop across the street from this hospital. Patient reports that she woke up this morning and drank 2 bottles of wine and injected heroin subcutaneously, per her daily routine, and then set out on a bus ride to buy more wine and ask people for money. After buying the wine, she spent a few hours behind the hospital asking people for money. Then she went to the bus stop across the street to catch a ride back to her apartment. This is the last thing she remembers before awaking in the ambulance while being transported to the ER. Patient denies any fever/chills, nausea/vomiting, chest pain, loss of bowel or bladder incontinence. She does report she becomes very ill when she stops drinking, and has had seizures and hallucinations in the past while withdrawing from alcohol. Pt has reported to the ER countless times over the past 5 years for a series of injuries both from assaults and falls, and has been found down and treated for alcohol intoxication and withdrawal in the past. She is also wheelchair-bound secondary to a R hip injury which she sustained in 2007.

-ER Doc

11 comments:

kds said...

I personally like the details... much easier for a normal person like me to read!

Side note-maybe I missed it but why did the lady go to the ER?

little d, S.N. said...

kds- "found down"- she was passed out when someone else called 911...so she might not have HAD something that SHE would consider to be "wrong" with her.

kds said...

Thanks little d. Missed that, I will have to start decoding these things.

little d, S.N. said...

the sheer number of times I've found myself wondering "wait...WHY am I looking at this person? WHY am I even IN this ambulance? while out on a run at night is astonishing, kds.

kds said...

It must be hard. You are a very brave person for what you do.

jillian said...

I like this: "per her daily routine"

Personally I like a bowl of raisin bran and a handful of vitamins. But 2 bottles of wine and some subcutaneous heroin, that works too.

ERP said...

Another "ER Super User"

SerenityNow said...

This had to be a psych resident/intern or a really ass-kissing med student note.

-Psych Doc

Ladyk73 said...

I loved the notes written by non-native english speakers... We had one resident that always had "so basically...." in the note. Just a simple word, but you can almost hear his accent in the written prose...

Nurse K said...

All we need to know is what year the wine was made.

Looks like a family practice resident note to me.

ER Intern said...

LoL I think the most important question is how is she still buying heroin from her wheelchair? Patients amaze me sometimes.