Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Article Comments

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*

You may also like these posts

Read comments »

Comments are closed.

Return to article »

Latest Interviews

Caring For Winter Olympians In Sochi: An Interview With Team USA’s Chief Medical Officer Dr. Gloria Beim

I am a huge fan of the winter Olympics partly because I grew up in Canada where most kids can ski and skate before they can run and partly because I used to participate in Downhill ski racing. Now that I m a rehab physician with a reconstructed knee I…

Read more »

How Do Hospital Executives Feel About Locum Tenens Agencies And Traveling Physicians?

I recently wrote about my experiences as a traveling physician and how to navigate locum tenens work. Today I want to talk about the client in this case hospital side of the equation. I ve had the chance to speak with several executives some were physicians themselves about the overall…

Read more »

See all interviews »

Latest Cartoon

See all cartoons »

Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

Read more »

See all book reviews »