So I heard that one of the departments here is trying to cut down on its cost of medical transcription. Here, as in most medical centers in the country, we no longer write our clinical notes. Just pick up the phone and dictate, and in 2 hours my note's all typed up for me to review on the computer and sign.
Apparently, that department spent US$400,000 last year on this alone. Though it is a high amount, considering we had over 1 million outpatient visits in the year of 2005 alone, doesn't seem excessive. Our department head was bugging us about it too, to the extent that he reviews our notes sporadically and does word counts and provide feedback. I suppose this is good practice for those wanting to go into private practice.
So when I started off working years ago, my notes would be long-winded and full of irrelevant information.
And then, I've learnt to be more concise and to the point.
This is a delightful 40-year old Caucasian man from Idaho presenting for evaluation of his poorly controlled type 2 diabetes mellitus. This was first diagnosed in 1984 when he developed polyuria and polydipsia. Complications include proliferative retinopathy status post photocoagulation, and nephropathy....
40-year old man with type 2 diabetes for 22 years, complicated by retinopathy and nephropathy....
Sick. Need treatment.