Archive for April, 2008

Have you ever thought about who looks at your charting? Too often, what is written in the chart is thought of in real time only. When we write down our history, our exam, lab values, etc we’re thinking about providing good care to the patient right now. We may, at times, realize that a little later down the road a consultant might need what we’ve written, or something, but rarely are we thinking much further down the road.

You need to change that, and do it now. If you think about the full context of what you’re writing now – in your training – you will form good habits that will stay with you throughout your career. Check this out…

I once received a note I had written 4 years prior (from when I was a resident). It was faxed to me for my review. It turns out that another hospital was being sued by a patient they transferred to my hospital on a night I was on-call. I wasn’t being sued, but they needed my deposition, since I was the first doc to see the patient after transfer was initiated. And even though I wasn’t being sued, I felt nauseated seeing a note I had written years ago come across the fax… from Dewey Soo Em and Howe.

Here’s an incomplete list of (potential) eyeballs on your hospital charting. Please add more in the comments if you think of others…

• Attending physician
• Covering attending physicians – usually on weekends
• Nurse – usually a new one every 12 hours
• Consultants
• Pharmacists
• Pharmacy techs
• Unit secretaries
• Interns and residents
• On-call coverage, moonlighters, etc
• Coding department
• Billing department
• Utilization review personnel
• Social workers and case managers
• Insurance company reps and reviewers
• Other hospitals’ staff/docs (on future hospitalizations)
• Lawyers
• Patients, themselves (Google and Microsoft are both have patient-directed health care records)
• ChartFarts.com (medical charting funnies – whatever you do, don’t end up here)

Be careful with what you write or enter into the computer.

Don’t shoot yourself and everyone you work with in the foot!

If you’re a doc, then you shoot others in the foot when you tell patients in the hospital that you’re going to order a certain medicine or a certain test – without telling them that it’s going to take some time.

If you’re a nurse, you’re shooting the doctor in the foot when you say, “I paged the doctor, but they never called back.”

The fact is that both may be true… but you need to give more information. Think about it from the patient’s point of view…

“The doctor just now told me that pain medicine is ordered. Why doesn’t the nurse get it right when I ask for it?”

“Why isn’t my doctor calling back? I’m sick enough to be in the hospital, you’d think they’d call back. He comes in for 5 minutes a day, at least call back when the nurse has a concern!”

It takes less than twenty seconds to change the way you say things, and in the process you can save the patient, other nurses, other doctors, patients’ family members, etc a lot of grief.

It’s all about managing expectations…

Many patients have never been in the hospital before. Many family members have never had someone so close to them in the hospital. Listen to what you say with their ears. See what they see.

They see the doctor in their room for 5 minutes a day… They don’t see the doc

1. Checking labs
2. Discussing things with consultants
3. Reviewing old records
4. Discussing the dispo with the case managers and social workers
5. Arguing Advocating for the patients with the insurance companies
6. Writing progress notes
7. Dictating consults
8. etc.

If you’re a nurse, you can change all of that if you just say something like, “Behind the scenes, we’ve all put our heads together and the doctor has reviewed your labs. Although she’ll be by a little later, she’s up to date on everything that’s been going on. She has some pretty sick patients on another floor.”

Likewise, the patients don’t know that when the you (Doc) write an order that…

1. The secretary has to take that order off
2. The secretary faxes it to the pharmacy or enters it into the computer
3. The secretary alerts the nurse or flags the chart
4. The nurse reviews the order
5. The pharmacy checks for duplicate orders, drug interactions, therapeutic substitutions, etc
6. The pharmacy sends the med up
7. And, finally the nurse brings the med to the patient

All it takes is saying something like, “I’m going to order a stronger pain medicine for you. But, I apologize, it’s going to take a little while for it to come up from the pharmacy.”