"It's In My Chart" The Patient Said. No It Isn't.

Don't you just love it when agitated patients show up to the ER or as a direct admission to the floor and the ER doctor or hospitalist or nurse is trying to ask them all the appropriate questions necessary to complete an accurate history and the patient's response is "It's in my chart."

Hey patients, I'm here to tell you it's not.  There ain't nothin' in your chart.  Remember the last time you told the nurse and doctor, "It's in my chart?"  Instead of looking for your answers in the chart, they simply wrote, "Patient refuses to answer all my questions" in your chart.  That became your chart. It also qualified you for mental health hospice benefits!

Now when you tell the medical team to go look in your chart, all they see is a statement that you refuse to answer any of their questions.  And since every history and physical will forever be copied and pasted from that moment on, you will never have a good documented history ever again if you tell your medical team just to look in the chart.

Bad for you. Good for us.  Thank you from the bottom of my heart.  That one statement allows me to skip your entire history and unobtainable ROS.  I still get credit from the Medicare National Bank for completing the highest level of service for a hospital admission.  Thank you for directing me to the chart.  "It's in my chart", you said.  I just documented what you told me to.  And the chart says you refused to answer any questions.  Bravo!  This crude medical ecard humor below helps explain this rarely used easy way out from the obnoxious E/M billing requirements.  It's even easier than documenting hospital visits based on time.  Any questions?

"If you answer 'It's in my chart' I will write "Patient refuses to answer' in your chart.  So the next time we meet, I'll know not to ask any questions.  Because, you know, it says so in your chart."

If you answer it's in my chart I will write patient refuses to answer in your chart doctor ecard humor

This post is for entertainment purposes only and likely contains humor only understood by those in a healthcare profession. Read at your own risk.

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