Posts Tagged ‘documentation’

Developing good documentation skills can be a tremendous part of your training – with profound implications for your patients, the effectiveness of consults you request, your evaluations from attendings, and developing efficiency for your future work. I have been called several times, thanking me for my documentation – by malpractice lawyers, by risk management personnel, and once by the Chief of Medicine at another hospital – you would be surprised at the information that others find useful in your old notes.

Anyway, here are a few tips I extracted from the Documentation Module of the RookieDoc Members area… Let me know what you think in the comments below or through email.

1. Know who reads your notes – you may be shocked at how many people rely on your documentation. If you know who these people are and what they are looking for, you will be light years ahead of others in your program.

2. Write legibly – If you work in a hospital or office that does not yet use electronic records, you better write legibly. It can have a huge impact on patient care, lawsuits, and your evaluations from attendings.

3. Use bulleted lists – Most people scan notes to the parts they think are important. If you list things like Past Medical History, recent tests and studies, Past Surgical History, recent hospitalizations, etc as bullets in a list, it will make it much easier for people that read the chart after you. You will stand out and your patients will be better for it.

4. Indent consistently – when making paragraphs or headings, do it in a consistent fashion. Avoid writing everything in one big blob of a paragraph.

5. Consistent order of things – from note-to-note, stay consistent.

6. Refer to other parts of the documentation – It’s okay to write, “See Dr. Smith’s review of the CT results in his note dated 12/13″ or “Exam is unchanged from 12/12″ or “See #2 above”. A good example of “see #2 above” may be if you have to refer to a problem more than once… like renal insufficiency in it’s own section, and then also again under diabetes.

7. Ask for specific feedback – ask attendings, risk management nurses, and upper level residents to look at your notes and give you feedback. And don’t accept answers like, “They’re good. Keep it up.” No. Ask specifically, “Well, what could I do better? What should I work on?”

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.”