rant reiteration

let me get something off my chest real quick. well i don't know how quick but we'll see. i'll start by saying this: medical reports follow a general format. emergency department reports, for example, tend to start with the heading "chief complaint," which is what the patient says the trouble is (common ones include "abdominal pain," "shortness of breath," "foreign body in naris," "tugging on ears," and [one of my faves] "found down").

then there's the "history of present illness" heading (or "hpi"), which is supposed to explain how the chief complaint came to be.

the heading most emergency room physicians use next is "past medical history." now, i do take issue with this. tell me it isn't redundant. it bugs me, so for the last several months i've just been typing "medical history" as the heading, and no one yet has come to yell at me.

i know i'm new to this gig and still idealistic, but really.

some doctors even say things (under subsequent headings "social history" or "habits") such as "the patient has a current history of smoking" - what is that?! i understand "remote history" and "recent history," but "past history"? "current history"?! i feel like i'm about to pop.

of course, if someone can explain to me the legitimacy of "current history," oh, please do. i'm all ears. if i'm missing something i'd like to know.

anyway, the "medical history" is pretty much what it sounds like. prior medical issues, chronic medical issues. doctors typically say things like "the patient has had a prior history of cholecystectomy in the past," and i pop again. "has had a prior history"?! and i do wonder when else the history of cholecystectomy would be. the future? i confess i've yet to hear a dictator say "future history," but that day could be coming.

and then we typically get a "review of systems." this, to my understanding, is the patient's subjective assessment of her or his person. the system subheadings include "respiratory," "cardiovascular," "gastrointestinal," "genitourinary," "musculoskeletal," "integumentary," etc, but most of the time in these emergency reports the time-sensitive doctor just says something like, "all systems are reviewed and are otherwise negative except as stated above in the hpi."

now, of course this sentence troubles me too. "otherwise negative except as stated above"? what does that mean? anyone want to diagram this for me?

not a small part of my job is, clearly, fixing the stupid things doctors say, so their reports don't make them look like fools. but i look at a lot of old reports in the course of a day and notice that most transcriptionists don't fix these kinds of redundancies. everyone else uses "past medical history" as a heading. can i be the only one who sees this as redundant? the only one who is bothered?

or is there truly something to it that i am missing? should i abandon my crusade?


fyi:
ombrophobia is a morbid fear of rain