In the age of hospitalists and electronic health records (EHRs), I’ve observed a decline in comprehensive physician assessments. I commonly see the first 3-4 sentences of the ER history of present illness (HPI) reappear verbatim in multiple provider notes. I seldom see a social or functional history, and rarely see accurate personal contact information. I observe a long list of past medical diagnoses and habits that are always documented (quality indicators linked to payment).  When a palliative care consultation is conducted, the documented focus often appears to be limited to the immediate problem. I wonder if the new generation of physicians and advanced practice practitioners providing post-acute rehab services has a similar “moment in time” focus, and wonder if there are measurable differences in patient and family satisfaction metrics or in facility outcomes. 

Personally, I enjoy getting to know my rehab patients, their support system, their pre-hospitalization functional status, and the details of their medical problems that could potentially impact their recovery. In a recent assessment of a woman transferred for rehab of a left hip fracture, I saw that she had fallen due to weakness of her left lower extremity, but I didn’t see an explanation. I also saw that she had been hospitalized at another hospital earlier this year for necrotizing pancreatitis with subsequent diabetes. No cause for either problem was specified. She was taking a proton pump inhibitor (PPI) and sucralfate, but their indication was not identified. Under allergies, I saw” NKDA” (no known drug allergies).  No mention was made in any portion of the chart that she and her sister still ran a very successful high-tech company or that her sister was a capable caregiver. 

The patient reported previous treatment for obesity with semaglutide (Wegovy), which was tolerated. Due to a desire for further weight loss, she was switched to tirzepatide (Zepbound).  Shortly thereafter, pancreatitis occurred. No other cause was discovered. Eliquis was prescribed for a deep venous thrombosis (DVT) complication.   A left calf hematoma developed and required incision and drainage (I & D). She subsequently had outpatient physical therapy for several months, but no longer needed a walker or cane at the time of this fall. She told me sucralfate had been added for gastritis complicating prior meloxicam (Mobic) use, although the meloxicam had been discontinued. Her gastritis and Eliquis use had resulted in iron deficiency, which explained her chronic daily ferrous sulfate orders. 

With this information, our rehab team better understood her LLE weakness and how that might impact her recovery. I also identified tirzepatide as an allergy and meloxicam as a drug intolerance. Sucralfate was continued. Because she has a history of reasonably high pain tolerance, she agreed to reduced exposure to opioids and their potential adverse effects. She agreed to spend most of the day out of bed, wear comfortable shoes, and dress warmly so she could obtain daylight and fresh air in our courtyard. With her supportive sister, and the adjusted care plan, I anticipate a short rehab stay, which will help our “bottom line” (PDPM) and LOS (Length of Stay) metrics. 

I know that this approach takes a bit more time, but the added information obtained may improve our care plans, measurable outcomes, and our relationships with patients and their families.