The phrase “normocephalic/atraumatic” is shockingly common in medical documentation. Often, it’s the only observation recorded about our patients’ heads. The phrase is meant to suggest that the patient’s head is proportional to his body, is normally shaped, and doesn’t have any signs of physical injury (like cuts or bruises). Admittedly, these can be valuable observations, especially in patients with other signs of trauma or developmental disorders. But is that information really useful in evaluating every patient? When you admitted that patient with diarrhea, did you really need to document that (surprise!) she didn’t have a massive scalp laceration or a deformed skull?
Even worse, most of the time students and residents document that the head is “normocephalic/atraumatic” without examining it at all. There’s a word for that: lying. Did you palpate the skull for depressed fractures? Did you look for lacerations hidden by the patient’s hair? Did you (gasp) measure the patient’s head circumference? If you’re not a pediatrician, do you even know what the average head’s circumference is? I’ll admit that I have absolutely no idea. But since I don’t measure heads, don’t carry a growth chart, and never assess for shape, I don’t pretend that I’ve evaluated those things. If I’m really trying to do a thorough head-to-toe exam, I look for scalp lacerations, raccoon eyes, Battle’s sign, and palpate for depressed skull fractures; if I don’t find any of those things, I document that by writing “no scalp lacerations, no depressed skull fractures, and no periorbital or mastoid ecchymoses.” If you have to examine a certain number of systems to bill for your time, either take the time to actually examine the head or look elsewhere for your freebies.
I do lots of things wrong. In fact, I probably do more things wrong than right; after all, I’m a marginally competent third-year medical student, not a chief resident at Mass General. But I do try to accurately document only those things that I’ve actually examined.