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Wording on Charts That Drives Me Crazy

Author Information (click to view)

Skeptical Scalpel

Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last three years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 1200 page views per day, and he has over 7300 followers on Twitter.

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Skeptical Scalpel (click to view)

Skeptical Scalpel

Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last three years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 1200 page views per day, and he has over 7300 followers on Twitter.

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Why do history and physical write-ups sound like transcriptions of interrogations? And who is teaching medical students to write things like "normocephalic"?

As I exist on the brink of extreme crankiness every day, it doesn’t take much to push me over the edge. Here are some things that do.

Why do history and physical write-ups sound like transcriptions of interrogations? Specifically, why to doctors write, “Patient denies alcohol use”? It’s as if the patient has been accused of using alcohol, and when she says she doesn’t drink, we say she “denies” it. In my experience, the vast majority of patients tell the truth during H&P interviews. There’s a difference between saying, “Patient doesn’t drink alcohol” and “The patient denies alcohol use.”

In reference to the examination of the head, eyes, ears, nose, and throat, who is teaching medical students to write things like this:

“HEENT: normocephalic, atraumatic.”

With the exception of Joseph Merrick, who lived in the 19th century and was known as “The Elephant Man,” just about every person I have ever seen is normocephalic. And other than those who have suffered an injury, the heads of most patients show no trauma.

It is important for a physician to know how to write a coherent sentence and spell words correctly. Poor spelling and grammar reflect either ignorance or sloppiness. Take the word “guaiac” for example. It refers to a reagent used less frequently now for the testing of the stool for blood. It is not spelled “guiac” or “guaic.” If you can’t spell it, use the word “heme” or simply write, “The stool test for blood was negative.”

Worst of all is misstating the plural of the word “diverticulum.” I have seen colorectal surgeons and gastroenterologists, both of whom should know better, refer to more than one diverticulum as “diverticuli” or “diverticulae.” Listen up, people. Diverticulum is derived from a Latin word. Its gender is neuter. Maybe you can remember it by considering other similar words: one bacterium, many bacteria; datum, data; stratum, strata.

Having said all this, I feel better now.

Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last three years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 1200 page views per day, and he has over 7300 followers on Twitter.

8 Comments

  1. No word destroys the literacy of a dictation faster than “did.” Spelling errors are most often those of a transcriptionist. Excessive helping verb use is in the dictation. Also, please spare us the litany of lab results placed diligently in the history of present illness unless the patient arrived in your office complaining of “a sodium of 122, potassium of 6.9, and a troponin of 12.”

    Reply
    • All of you comments are valid. You sound like me.

      Reply
  2. My goodness, you are crabby! LOL. I have my moments, too. Physicians and other healthcare personnel who insist on speaking entirely in medical jargon when “communicating” with patients and family members.
    PS: Had my rotator cuff repair 11/1. They sent me home with a grenade full of local with a tiny catheter running under the skin. It lasted 3 days and that was a huge help in the pain department.
    Six more weeks in the sling with my elbow pinned to my side might make me crazy: I hate sleeping in a recliner chair. I can’t tweeze my eyebrows with one hand. I can’t cut meat. Styling my hair with one hand was a nonstarter! Good things: when this is all over, I will have two good shoulders!

    Reply
    • Yes, I am crabby. Sorry I missed this comment for a few days. I’m now 7 weeks out. No longer need the sling, but I do sleep with it on. I just feel more comfortable with it. I can sleep on my non-operated side now too. My range of motion is improving a lot. You will get there soon. The first two weeks are the hardest.

      Reply
  3. I was taught that “normocephalic/atraumatic” should only be used in writing up the physical exam of a newborn – as in – no stigma of birth trauma, no evidence of micro/macrocephaly.

    Reply
    • That makes sense. Thanks for commenting.

      Reply
  4. I’m a PA. In school it was BEAT into our heads to use this legalistic, defensive terminology when dictating an H&P. I still use “normocephalic and atraumatic” to this day, just out of habit. I think schools are so obsessed with medical/political ‘correctness’ that they never allow students to improvise or use more common language. Also the fear of litigation or denied reimbursement is huge so we are always trying to word things in such a way that gives an unequivocal impression of a thorough exam.

    Reply
    • I like the way you said “gives the unequivocal impression of a thorough exam.” I think people think it sounds thorough, but really, it’s meaningless.

      Reply

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