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? Read more »
*This blog post was originally published at edwinleap.com*
