This is a faxed note from a physician’s office about someone you don’t know.
This is fairly typical of a modern EHR note “created” (or stillborn) by clicking on word choices from a list. The lists are designed with an eye toward being able to bill for the actual work done during the visit. The result is awful. Every doctor in the world would agree.
We can do better. We must try. Think of the reader caring for this patient later.
This would have said the same thing:
He is here to follow-up on his SLE with renal disease, moderate proteinuria, hypertension, and hyperlipidemia.
A slightly more readable version (because it's a list) would be:
He is here to follow-up on his:
- SLE with renal disease
- moderate proteinuria
I think we physicians need to tell patients' stories, not just collect bullet points for billing. A well crafted, readable narrative will contain the data to justify the billing. If our typing skills are weak, we can learn voice recognition.