Not just ILPs - Mountainwoman Posted: Nov 7th, 2016 - 8:01 am In Reply to: As a QA person, I believe it's probably mostly ILPs, sad to say. - nm
I would estimate about 80% of the reports I get to QA from our BoB do not have appropriate headings. There is HPI information under a medication heading, social history information under Family History, etc., if there are headings at all. The physical exams are the ones that kill me. There is always extremity information under an abdomen subheading, etc. Also, the exams are supposed to be cap headings, justified left. This is what I see on just about every report:
Pleasant female in no acute distress.
HEENT: PERRL.
No rales or rhonchi.
EXTREMITIES: No edema. No organomegaly.
I know our group gets a lot of people who are new to the MT field, but these are not just new graduates and none are ILPs. I'm not sure if they don't know better or don't care. Either way, it's just sad.
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