Today, the EMR has replaced that thoughtful activity with a series of short cuts and phrases that can be quickly populated into a note, which is ultimately used to justify hospital and physician billing. Certain phrases must be present to attain the desired level of billing. As a critical care physician, I can easily meet the highest mark with the phrase, “respiratory failure.”
Category: pediatric critical care
Palpable Pulses
Each time I examine a baby with a heart defect, I comment in my progress note on the nature of their pulses and the state of their perfusion. "Pulses are full and the baby is warm and well-perfused." Of course, no pediatric exam is complete without examination of the parent, but those important facts don't [...]
Gwen Erkonen, MD 