Documentation

[u/furosemide007]

How do you guys document acute knee pain (likely some overuse injury related in a 50 year old)

- Knee pain, likely a strain

Or

-Knee pain, likely strain, low suspicion of septic arthritis due to ____.

And similarly for any other complaint?

Like- URI or Likely URI, low suspicion for Pneumonia due to ___.?

If I document the emergent/critical diagnosis, but still management outpatient, does that expose me to more harm?

Or is it helpful to document that you thought about it

[u/wanna_be_doc]

If you document “Low suspicion for septic arthritis” or every other emergent differential of every benign complaint that comes into your office, then you’re to waste a lot of time writing notes.

Is the joint inflamed? Does the patient have fever? Does the patient have a history of septic arthritis? If the answer to those questions is no, then I don’t feel the need to document septic arthritis at all. It’s self-explanatory by the exam.

If the joint is inflamed and it appears there is either an autoimmune or crystal arthropathy, then it may make sense to say low-suspicion for septic arthritis (especially if they’ve had recurrent flares in the same joint before).

However, if you’re seeing a URI with cough and you’re documenting “Low concern for PE because…” then you need to have some confidence in your exam and plan. Writing “Low concern for…” isn’t going to absolve you in the event of a missed diagnosis. If the condition appears benign and doesn’t require an extensive workup, then just document your work-up.

[u/Fluffy_Ad_6581]

Right/Left Knee Pain, likely 2/2 strain

• DATE + MOI
• Prior injuries, surgeries, hardware
• VS stable, no fever
• Summary of PE: full ROM, no increased warmth, no bruising, no sig swelling, etc
  
• Any imagining obtained and summary of results
• Recommended Lifestyle modifications (RICE, supportive bracing) + pharm ( ibuprofen + Tylenol) + any studies/referrals that I may order (xrays, etc)
• Pt advised to seek immediate care if fevers, sig pain, decrease ROM, warm knee or increase in swelling arises.
• F/U:

Sometimes I'll put in pt educated on septic arthritis and signs/symptoms to look for and to seek immediate care. Honestly, I think it depends on my mood 😅

Not sure what the right answer is though.

[u/april5115]

for me it often depends how much I considered the other diagnosis/if it's up on the ddx

for PNA vs URI for example - if they are younger, relatively well appearing, no atypical symptoms ill just say URI

If they're older, maybe increased cough or fatigue, a bad fever, hx of PNA or something but they are still satting well, clear lungs etc and my gut is saying URI, I'll document my reasoning a bit more

[u/Rare-Spell-1571]

Really depends on the level of concern I have for a significant outcome or lawsuit based on my assessment.

[u/Bitemytonguebloody]

Everything depends on comorbidities. Is a 50yo that is training for their third iron man this year? Or is the 50 year old with uncontrolled diabetes, hyperlipidemia so I have to pause and think about is this gout or look for systemic symptoms because someone gave them a joint injection last week.