In a feat as miraculous as the orthopedic surgeon writing a SOAP note without using any words, a surgical resident successfully composes a consult note only using copy-and-paste.
Dr. Henry Fast was rotating on pediatric surgery when asked to rule out appendicitis on a febrile, encephalopathic child with abdominal pain. Parents were asleep when he examined the child at 4:45 AM, so he obtained additional information from the electronic medical records.
He gleefully spotted an infectious disease consult note with the most detailed history ever recorded – including social history, diet and travel history, school field trips, pet exposures, insect bites, immunization records, herbal supplements, parents’ political affiliations, and recent antibiotic use – which he quickly copy-and pasted.
“OK, first part is done. What’s next?” he pondered, glancing at the time, 4:47 AM, realizing he had only a few minutes to spare.
Then he noted a beautifully written neurology consult exam, including full mental status testing, visual field assessment, detailed sensory testing to light touch, temperature, pin prick, 2-point discrimination, graphesthesia, vibration, and proprioception, and rectal tone and anal wink, which was “basically the same exam I did on the kid,” so he copied-and-pasted again.
It was now 4:48 AM, and he still needed to see the remainder of the consults and all the pre-op patients.
The lab findings and recent imaging results were a no-brainer. “Everyone copies-and-pastes those results.” He did insist, however, that he “independently reviewed pertinent imaging studies, and agree with findings. Clinical correlation suggested.”
He was almost done drafting his perfect note by 4:49 AM when Dr. Fast ingeniously remembered his colleague admitted a rule-out appy overnight. “It was meant to be,” he states, as the child was even around the same age and sex. He copy-and-pasted the impression and recommendations, by 4:50 AM, smiling at a job well done!
When his attending went to co-sign the note, she thought that his note seemed a bit long, but did not really have time to read it in its entirety. She inserted her generic linking statement “agree with above,” which she will do for the next 10 days of copy-and-paste iterations of the same original consult note.
Whew. Another life saved by electronic medical records!