Does no one understand headings anymore? - Dying breed

Every single time I look through previous reports, I see missing headings or incorrect headings.  Has anyone else noticed this?  Maybe we really are a dying breed.

Is it just me or if you are typing an HPI, you start with History of Present Illness, not just nothing?  We have all been doing this forever!  Headings.  You never used to see reports that just started with no heading at all.

If you are doing a physical exam and the doctor stops talking about heart sounds and starts talking about bowel sounds, you don't just put that under Heart.  Right?  You make a new heading.  And a new heading for Assessment, Laboratory Data, whatever.  Unless it's verbatim, of course, but I'm just talking about the average non-verbatim account.  Does no one learn about headings anymore?  Wouldn't you feel weird about including the extremity exam under Abdomen?

I have been on the same 20 accounts for 10 years.  It's a hard account and the docs are picky and the reports can be complicated and the CPs are all alike but with little variations that are easy to miss, and I know these doctors want headings.  It even says this in the CP.  But that is what I was trained to do anyway:  Except on verbatim accounts, you add headings to make the report look nicer.

So why do so many reports not do this?  Am I seeing ILP work?

Oh well.  I know we have a bunch of bigger problems these days, but this has been driving me crazy.  Maybe it's not taught this way anymore, I don't know.

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• Does no one understand headings anymore? - Dying breed (Views: 923, 2016-11-06, 9:06 pm)
  • I agree with you - anon (Views: 544, 2016-11-06, 11:06 pm)
  • As a QA person, I believe it's probably mostly ILPs, sad to say. - nm (Views: 592, 2016-11-07, 5:40 am)
    • Not just ILPs - Mountainwoman (Views: 506, 2016-11-07, 8:01 am)
      • This is exactly what I see every single time - Dying breed (Views: 542, 2016-11-07, 8:21 am)
  • I'm not paid for headings so I'm no longer very - concerned about them. (Views: 545, 2016-11-07, 5:52 am)
    • Not true. You are paid for headings. You're not paid for headers and footers. Good grief! - nm (Views: 476, 2016-11-07, 6:10 am)
    • OMG. Read your Rewards Plan in Inner Circle. You are even paid - sm (Views: 769, 2016-11-07, 6:35 am)
      • Yeah that makes us feel SO special. - mm slave (Views: 620, 2016-11-07, 7:04 am)
  • I was marked off on audit for adding heading - sm (Views: 717, 2016-11-07, 7:59 am)
    • Shame on that auditor - Dying breed (Views: 668, 2016-11-07, 8:37 am)
      • We don't get paid to fight audits - sm (Views: 492, 2016-11-07, 9:21 am)
      • "includes" - sm (Views: 393, 2016-11-07, 1:20 pm)
        • Makes sense - Dying breed (Views: 495, 2016-11-07, 1:46 pm)
    • And therein lies the problem - sm (Views: 563, 2016-11-07, 9:20 am)
    • I've had the same problem - MT2002 (Views: 319, 2016-11-08, 11:42 am)
      • Apologies - Dying Breed (Views: 499, 2016-11-08, 7:26 pm)
  • You get what you pay for - pretty simple...nm (Views: 482, 2016-11-07, 9:17 am)
    • If that is our attitude - They may as well (Views: 768, 2016-11-07, 9:31 am)
      • they know they suck - sm (Views: 500, 2016-11-07, 10:02 am)

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