Richard Rathe, MD

Associate Professor of Family Medicine (ret.) and Medical Informatician

Posts Tagged ‘clinical documentation’

An Alternative Symptom Score to Replace the Overused 10 Point Pain Scale

Posted: Jun 22nd, 2019 •• Category: HPI, Medicine

If you take a 3pt functional symptom scale and couple it with a 3pt frequency scale you have a 3×3 grid that might work better than a one dimensional 10pt scale.

ShortNote – Clinical Shorthand 1.0

Posted: Aug 17th, 2017 •• Category: EMR, HPI, Patient Care

I have worked with home-grown and commercial Electronic Medical Records for over thirty years. The use of “dot commands” (a period followed by a trigger phrase) is about as old as personal computing. (I first encountered dot commands in the WordStar word processing program during the 1980s!) These commands generally fall into three categories: a) links to retrieve […]

“Least Ink” Principal for Medical Documentation

Posted: Aug 12th, 2014 •• Category: EMR

The best clinical documentation is that which gives to the reader the greatest amount of information in the shortest time with the fewest pixels. Paraphrased from Edward R. Tufte The Visual Display of Quantitative Information  During April 2014 I gave a talk at an EMR meeting concerning the changes manifest in the everyday clinic note. […]