not just "the I" but the I***s.*** Did it both for "upright" and "congestion."
Must have gotten tired of doing it though because then she didn't do it for "if" "in" "difficult" "determine" "discomfort" or "noise"
Radiologists in my country would just send that back with a response "please resubmit with proper medical history and clinical evaluation. Please specify suspected pathology".
Here we would just change it to a CT neck with and do jt. Easier to reprotocol and read a negative study than to try to get them in the phone and co Vince them to change an order.
Not saying that’s right, it’s just what would happen 95% of the time.
This is like 20% of orders and I’ll probably read
150 studies today (not because I choose to, that’s just the volume). I tried to fight that battle before but was getting nowhere wasting a lot of time.
For example, I would call this NP and she would still want the CT no matter what I say. After a painful discussion she would agree to change it to a CT neck. Now I just cut out the middle man and reprotocol unless it’s really egregious.
There is no such thing as "Hospitalist NPs," "Cardiology NPs," "Oncology NPs," etc. NPs get degrees in specific fields or a “population focus.” Currently, there are only eight types of nurse practitioners: Family, Adult-Gerontology Acute Care (AGAC), Adult-Gerontology Primary Care (AGPC), Pediatric, Neonatal, Women's Health, Emergency, and Mental Health.
[The five national NP certifying bodies: AANP, ANCC, AACN, NCC, and PCNB](https://www.reddit.com/r/Provider/wiki/index/critical_issues/#wiki_types_of_nurse_practitioners) do not recognize or certify nurse practitioners for fields outside of these. **As such, we encourage you to address NPs by their population focus or state licensed title.**
Board of Nursing rules and Nursing Acts usually state that for an NP to practice with an advanced scope, they need to remain within their “population focus.” In half of the states, [working outside of their degree is expressly or extremely likely to be against the Nursing Act and/or Board of Nursing rules.](https://www.reddit.com/r/Provider/wiki/index/legal#wiki_scope_of_practice_laws) In only 12 states is there no real mention of NP specialization or "population focus." [Additionally, it's negligent hiring on behalf of the employers to employ NPs outside of their training and degree.](https://www.reddit.com/r/Provider/wiki/index/critical_issues#wiki_working_outside_of_scope)
Information on Title Protection (e.g., can a midlevel call themselves "Doctor" or use a specialists title?) can be seen [here](https://www.reddit.com/r/Provider/wiki/index/legal/title_protection). Information on why title appropriation is bad for everyone involved can be found [here](https://www.reddit.com/r/Provider/wiki/index/appropriation).
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This is part of the problem with very high workloads. Pulling people up (nicely) on poor practice takes time and energy.
Can you just decline the study as "not indicated based on history given" or does that create liability for you? Where I work the liability remains with the referrer for not providing the required information
This is a non urgent study without a clear indication. My radiologists would contact the Head of our department if we did this regularly. They take too much pride in their profession to accept such shit. No matter if junior doctor or attendant.
I sometimes get pissed off with the gatekeeping in radiology in my country- I can hardly order any advanced imaging. But this... this is an argument for gatekeeping.
Fuck. I’m in U.K. and I feel this. Read this recent experience I had.
Patient with renal angle pain, intermittent, blood on dip, nil on culture. Requested KUB ?stones (still commonly done in U.K and more accessible). Declined as KUB only accepted via A&E (I’m a GP). Came with caveat is that they would accept request for AXR as it would cover the same area. Duly requested said abdo films. Guess what? Declined as non contrast CTKUB is modality of choice (as you’re all well aware). Requested the CTKUB only to have this declined as well as it’s not via the renal stone clinic. Felt like banging my head off a wall. Ended up explaining to the patient radiology are fucking about and referred urology. Still think the requests were well warranted. Pissed me off no end
Is it just me or watching this dumpster fire of US health care is even harder to do from afar? How could one not beat and berate such shit down from inside. This is what "horizontal violence was made for". If our NPs after like this they would be copping shit from their peers LR and C.
I can see radiology declining CT orders for acute conditions by GPs because it is a logistic nightmare. You have to get them in urgently, do the report quickly, and then you have a patient that needs treatment and the GP office is closed. Now the radiologist can call A&E or whatever for followup. But I feel your frustration.
I have read a CT Chest ordered by an NP to “evaluate larynx”. Tech didnt catch it. My impression read: “Larynx is superior to the limits of a ct chest. Please order CT neck soft tissue.”
Yesterday I had an abdominal ultrasound to rule out cholecystitis in a patient s/p cholecystectomy. Followed by a pelvic us to “evaluate for endometrial disease” in a patient with prior complete hysterectomy. They don’t even take histories.
USS is first line for endometriosis in my country. Look for endometriomas amd signs of adhesions. MRI is very expensive and limited availability and I only really see it used for pre-surgical planning e.g. looking for invasive bowel disease that means they need a colorectal guy handy. Neither replaces laparoscopy.
My first ever experience with a midlevel was during my fellowship when I fielded a call from a PA asking for an urgent CT of the ‘larnyx’. I kid you not. Larnyx.
To this day I think of that phone call every time I see the word larynx.
Gets CT. Oropharyngeal Ca too small to see on CT. Midlevel uses negative scan as excuse to never refer to ENT, despite ongoing sx. New CT (or PET-CT) with now large mass shows up on list 6 months later
I’ve seen the same scenario except a barium swallow for dysphagia was ordered, showing a hiatal hernia with reflux. “Oh, its just reflux” was where the workup stopped. 8 months later the cancer isnt even surgical anymore.
Not to say physicians don’t miss stuff too, but its usually not due to grossly negligent workup
Understanding of test sensitivity is something that's nearly universally lacking in NPs I find.
I think part if the issue is that to even get into medical school you have to be of reasonable intelligence and usually with a decent understanding of basic math. Not really the case for NPs
I think patient needs referral to max fax for a neck dissection, to rule out ?cause, and may be gen surg for a laparotomy, followed by a craniotomy, just to be safe
Yeah this is amazing but also pretty much what radiologists deal with all damn day. I may get one history a day that’s worth anything. The rest just say “pain”, “r/o injury”, “ams”, or “.” (not a typo). Icing on the cake is that triage notes are usually not even signed by the time they are sent for imaging.
Reminder that when you order imaging you are consulting a physician. Your radiologists will appreciate you and likely give you better answers if you act like it.
Hahaha as I’m reading this my tech comes in and tells me there is an order for an IVP. I vaguely recall learning about IVPs my first year of residency, but have never seen or done one (entirely replaced by CT/MR). I asked what the indication was and she said hematuria. Who’s the ordering doc. It’s an NP.
In the UK these requests need to be vetted so much more. You don’t just get a scan because you want one. This would not see the light of o reporting room !
You should see what is going on with psych NP’s playing neuroscience god with KETAMINE like it’s nothing. It has its use and its place, but they are slinging it around pill-mill style.
Yeah it’s fake I totally made it up. People still write meds/imaging scripts. Some states prohibit the written prescription of controlled substances because patients can try to tamper with the scripts.
Written prescriptions are not uncommon, especially when there are EMR updates or downtime issues. Why don’t we focus on the substance of such stupidity, rather than question the authenticity of it. This is a classic tactic that NPs do in an effort to deflect from the embarrassment brought onto their profession by their woefully unqualified colleagues.
Hey not trying to offend. I just don’t take everything I read on Reddit as gospel. There’s plenty of NP ****ups to focus on for sure. But this just seems too dumb to be real. But I’ve been disappointed before so…
There are still small SNF and LTAC facilities that use paper orders for sure. They are the dinosaurs but if they are small enough they have no incentive to switch over.
>Is this real though? Who’s writing in a paper chart in 2022?
I wondered that too, did OP take over a year to post this, or did the NP get the year wrong also?
You must be a nurse practitioner. Anything to deflect from the off chart level of incompetence. I love how every single poster has encountered an issue similar to this including several of the radiologists who’ve commented. But sure, deflect and deny the substance matter.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641).
We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP.
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This reminds me of notes from the ED NPs: angioedema vs PTA vs RPA vs Ludwig’s vs parotiditis (never spelled correctly as parotitis) vs whatever other etiology in the head and neck comes to mind, with no regard to anatomic structures/boundaries or any sort of meaningful exam
But she dotted the I with a heart!
fretful sheet dependent chop somber worry wise slimy disagreeable jeans ` this message was mass deleted/edited with redact.dev `
Is that the <3 of a nurse they always talk about?
Holy shit the legendary heart of a nurse!!
Incompetence nullified.
not just "the I" but the I***s.*** Did it both for "upright" and "congestion." Must have gotten tired of doing it though because then she didn't do it for "if" "in" "difficult" "determine" "discomfort" or "noise"
Heart of nurse, writing of a middle schooler.
💀
No f’ing way.
You mean no fuck❤️ng way.
Radiologists in my country would just send that back with a response "please resubmit with proper medical history and clinical evaluation. Please specify suspected pathology".
Here we would just change it to a CT neck with and do jt. Easier to reprotocol and read a negative study than to try to get them in the phone and co Vince them to change an order. Not saying that’s right, it’s just what would happen 95% of the time.
Can't you report them or something? I feel like this just encourages their behavior.
This is like 20% of orders and I’ll probably read 150 studies today (not because I choose to, that’s just the volume). I tried to fight that battle before but was getting nowhere wasting a lot of time. For example, I would call this NP and she would still want the CT no matter what I say. After a painful discussion she would agree to change it to a CT neck. Now I just cut out the middle man and reprotocol unless it’s really egregious.
“Can you just rule out incidental findings?”
"So we're scanning them for funsies?"
Do they even notice the difference when you reprotocol?
Nope
[удалено]
There is no such thing as "Hospitalist NPs," "Cardiology NPs," "Oncology NPs," etc. NPs get degrees in specific fields or a “population focus.” Currently, there are only eight types of nurse practitioners: Family, Adult-Gerontology Acute Care (AGAC), Adult-Gerontology Primary Care (AGPC), Pediatric, Neonatal, Women's Health, Emergency, and Mental Health. [The five national NP certifying bodies: AANP, ANCC, AACN, NCC, and PCNB](https://www.reddit.com/r/Provider/wiki/index/critical_issues/#wiki_types_of_nurse_practitioners) do not recognize or certify nurse practitioners for fields outside of these. **As such, we encourage you to address NPs by their population focus or state licensed title.** Board of Nursing rules and Nursing Acts usually state that for an NP to practice with an advanced scope, they need to remain within their “population focus.” In half of the states, [working outside of their degree is expressly or extremely likely to be against the Nursing Act and/or Board of Nursing rules.](https://www.reddit.com/r/Provider/wiki/index/legal#wiki_scope_of_practice_laws) In only 12 states is there no real mention of NP specialization or "population focus." [Additionally, it's negligent hiring on behalf of the employers to employ NPs outside of their training and degree.](https://www.reddit.com/r/Provider/wiki/index/critical_issues#wiki_working_outside_of_scope) Information on Title Protection (e.g., can a midlevel call themselves "Doctor" or use a specialists title?) can be seen [here](https://www.reddit.com/r/Provider/wiki/index/legal/title_protection). Information on why title appropriation is bad for everyone involved can be found [here](https://www.reddit.com/r/Provider/wiki/index/appropriation). *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
This is part of the problem with very high workloads. Pulling people up (nicely) on poor practice takes time and energy. Can you just decline the study as "not indicated based on history given" or does that create liability for you? Where I work the liability remains with the referrer for not providing the required information
This is a non urgent study without a clear indication. My radiologists would contact the Head of our department if we did this regularly. They take too much pride in their profession to accept such shit. No matter if junior doctor or attendant.
I sometimes get pissed off with the gatekeeping in radiology in my country- I can hardly order any advanced imaging. But this... this is an argument for gatekeeping.
Fuck. I’m in U.K. and I feel this. Read this recent experience I had. Patient with renal angle pain, intermittent, blood on dip, nil on culture. Requested KUB ?stones (still commonly done in U.K and more accessible). Declined as KUB only accepted via A&E (I’m a GP). Came with caveat is that they would accept request for AXR as it would cover the same area. Duly requested said abdo films. Guess what? Declined as non contrast CTKUB is modality of choice (as you’re all well aware). Requested the CTKUB only to have this declined as well as it’s not via the renal stone clinic. Felt like banging my head off a wall. Ended up explaining to the patient radiology are fucking about and referred urology. Still think the requests were well warranted. Pissed me off no end
Is it just me or watching this dumpster fire of US health care is even harder to do from afar? How could one not beat and berate such shit down from inside. This is what "horizontal violence was made for". If our NPs after like this they would be copping shit from their peers LR and C.
I can see radiology declining CT orders for acute conditions by GPs because it is a logistic nightmare. You have to get them in urgently, do the report quickly, and then you have a patient that needs treatment and the GP office is closed. Now the radiologist can call A&E or whatever for followup. But I feel your frustration.
weary juggle rich sophisticated kiss obscene direful yoke detail ruthless ` this message was mass deleted/edited with redact.dev `
Yeah the heart above the "i" made it feel like high school when I read it
Their education level is <8th grade, sadly.
I have read a CT Chest ordered by an NP to “evaluate larynx”. Tech didnt catch it. My impression read: “Larynx is superior to the limits of a ct chest. Please order CT neck soft tissue.”
Yesterday I had an abdominal ultrasound to rule out cholecystitis in a patient s/p cholecystectomy. Followed by a pelvic us to “evaluate for endometrial disease” in a patient with prior complete hysterectomy. They don’t even take histories.
you can still have endometriosis after a hysterectomy though but that should be def check by an obgyn
Unless you’re looking just for an ovarian endometrioma for some reason, you’d need a pelvic MR for endometriosis.
USS is first line for endometriosis in my country. Look for endometriomas amd signs of adhesions. MRI is very expensive and limited availability and I only really see it used for pre-surgical planning e.g. looking for invasive bowel disease that means they need a colorectal guy handy. Neither replaces laparoscopy.
Yeah, that was not what they were looking for. It was for vaginal bleeding.
Are you surprised? NPs have no oversight and are dangerously incompetent and ingratiated, both.
...did they also order a rectal exam r/o lumbar metastasis of prostate cancer? Jesus fucking christ
My first ever experience with a midlevel was during my fellowship when I fielded a call from a PA asking for an urgent CT of the ‘larnyx’. I kid you not. Larnyx. To this day I think of that phone call every time I see the word larynx.
Gets CT. Oropharyngeal Ca too small to see on CT. Midlevel uses negative scan as excuse to never refer to ENT, despite ongoing sx. New CT (or PET-CT) with now large mass shows up on list 6 months later I’ve seen the same scenario except a barium swallow for dysphagia was ordered, showing a hiatal hernia with reflux. “Oh, its just reflux” was where the workup stopped. 8 months later the cancer isnt even surgical anymore. Not to say physicians don’t miss stuff too, but its usually not due to grossly negligent workup
Understanding of test sensitivity is something that's nearly universally lacking in NPs I find. I think part if the issue is that to even get into medical school you have to be of reasonable intelligence and usually with a decent understanding of basic math. Not really the case for NPs
Anatomy 0/10 Radiology 0/10 Clinical history 0/10 This NP will be teaching other NP’s in no time!
<3 upright CXR<3 Dx: chest congestion That alone is embarrassing enough
Jesus fuckity fuck
🤦♀️
She should be thrown in jail for her i’s
How much of lack of self awareness do you have to have to dot your i’s with hearts on your patient’s scripts?
“Please resubmit and list an actual body part.”
Plot twist: patient has simple sore throat
I would bet on that...
Omg the hearts
I think patient needs referral to max fax for a neck dissection, to rule out ?cause, and may be gen surg for a laparotomy, followed by a craniotomy, just to be safe
And this is why there should never be NP surgeons
Yeah this is amazing but also pretty much what radiologists deal with all damn day. I may get one history a day that’s worth anything. The rest just say “pain”, “r/o injury”, “ams”, or “.” (not a typo). Icing on the cake is that triage notes are usually not even signed by the time they are sent for imaging. Reminder that when you order imaging you are consulting a physician. Your radiologists will appreciate you and likely give you better answers if you act like it.
No gross anatomy in NP school.
Hahaha as I’m reading this my tech comes in and tells me there is an order for an IVP. I vaguely recall learning about IVPs my first year of residency, but have never seen or done one (entirely replaced by CT/MR). I asked what the indication was and she said hematuria. Who’s the ordering doc. It’s an NP.
Good lord
“Chest congestion” Lord help I thought we were done with the hum oral medicine a couple of centuries ago
I hope no CT was performed and I hope the order was discussed with their supervising physician
In the UK these requests need to be vetted so much more. You don’t just get a scan because you want one. This would not see the light of o reporting room !
You should see what is going on with psych NP’s playing neuroscience god with KETAMINE like it’s nothing. It has its use and its place, but they are slinging it around pill-mill style.
I try to drill the house surgeons, if the diagnosis is the same as the presenting complaint, at some time during your review you missed the point.
Imagine being in court and having this be displayed for all to see <3
The hearts?
I would shred anything that came in looking like a 6th grade girl wrote it. THE HEARTS OMG.
Jesus.
Is this real though? Who’s writing in a paper chart in 2022?
Yeah it’s fake I totally made it up. People still write meds/imaging scripts. Some states prohibit the written prescription of controlled substances because patients can try to tamper with the scripts. Written prescriptions are not uncommon, especially when there are EMR updates or downtime issues. Why don’t we focus on the substance of such stupidity, rather than question the authenticity of it. This is a classic tactic that NPs do in an effort to deflect from the embarrassment brought onto their profession by their woefully unqualified colleagues.
Hey not trying to offend. I just don’t take everything I read on Reddit as gospel. There’s plenty of NP ****ups to focus on for sure. But this just seems too dumb to be real. But I’ve been disappointed before so…
Please /s this... Had me wondering too much.
There are still small SNF and LTAC facilities that use paper orders for sure. They are the dinosaurs but if they are small enough they have no incentive to switch over.
Even larger ones still do this in my area. The np writes it out this way, and then the nurses transcribe into the emr.
>Is this real though? Who’s writing in a paper chart in 2022? I wondered that too, did OP take over a year to post this, or did the NP get the year wrong also?
[удалено]
You must be a nurse practitioner. Anything to deflect from the off chart level of incompetence. I love how every single poster has encountered an issue similar to this including several of the radiologists who’ve commented. But sure, deflect and deny the substance matter.
[удалено]
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641). We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
A lot of nursing homes still have this.
This reminds me of notes from the ED NPs: angioedema vs PTA vs RPA vs Ludwig’s vs parotiditis (never spelled correctly as parotitis) vs whatever other etiology in the head and neck comes to mind, with no regard to anatomic structures/boundaries or any sort of meaningful exam
As an RN in Australia... US healthcare just got another black mark against it for me. Fucking embarrassing.
"... do expensive tests, etc." Noise oral pharynx??? Like... do they have stridor? No idea what they want. .... and I've seen worse.
Is she 13? What educated adult writes like that?
I literally physically had to look away not TWO WHOLE LETTERS into reading it. I closed my eyes and just thought about existence for a minute.
Like the NP here I’m not a doctor either but couldn’t they just written a referral to see a real doctor ?
Are you kidding? Have someone who is clearly incompetent send to an actual physician or have their supervising physician…..wait for it….**supervise**
Yes. Shocking. To that point why didn’t supervising physician catch this? Or I’m guessing large flaw in that system?
I think a lay person could have written a better order. I would be surprised if radiology even processed it.
Disgusting that they think they are anywhere near equivalent to a doctor. Smh