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Descriptive Charting And The Physical Exam

Our relatively new electronic medical record (EMR) product has prompts and clicks for everything imaginable. One of them, which we can use during the physical exam, is the long list of “constitutional” findings that we perceive on generally looking over the patient.

They include things like: Obviously ill, comfortable, uncomfortable, pale, well-nourished, well-hydrated, well-dressed, alert, chronically ill, contracted, emaciated — and so on.

But these descriptors don’t always cut it. I mean, people are both amazing and annoying, so why not add a few more to the list?

Here’s what I’d throw in there on the positive side: Beautiful, stylish, seductive, fit, solid, personable, amiable, good handshake, motivated, capable, supportive, supported, kind, gracious, patient, loving, peaceful, jovial, warm, inviting, educated, fascinating, cosmopolitan, humble, long-suffering, blessed, joyous, holy, and inspiring.

On the other side, I’d use: Angry, annoyed, introspective, disembodied, terrifying, cruel, bitter,  manipulative, rapacious, profane, grasping, dramatic, nasty, disturbing, creepy, cruel, hateful, petty, seductive (yes, it could go either way, as a matter of fact), felonious, hick, prude, arrogant, self-aggrandizing, xenophobic, and misinformed — for a start, that is.

As a disclaimer, all of these could be used to describe physicians as well, depending on their degree of rest, state of mind, level of fatigue, and general humanity.

Words have power, and I think these will convey the sense of the doctor-patient encounter far more precisely than your standard “awake, alert, oriented.”

*This blog post was originally published at edwinleap.com*


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