As a doctor, huge amounts of time are spent documenting things. For this reason, templates can be very helpful as a time saving device. But the most important thing is to make sure to edit the template carefully.
When I was a PGY2 rotating at the VA, I admitted a woman for rehab for a right hip replacement. I used the "Hip Replacement" template in writing up her H&P, which was basically an H&P that had been done on a prior hip replacement patient.
A few days later, I was looking over the woman's H&P and to my horror, I realized that I had referred to the patient in the physical as a "Pleasant Somoan gentleman." And since I had already electronically signed the document, it was not editable, so there was no way to correct it. To my second horror, my attending had written an addendum that said, "Correction: Patient is a Caucasian female and not a Somoan gentleman."
Here's the worst part:
About a year later, I was rotating at the VA again, and that same woman came back to have her left hip done. I had my templates ready, and even though I told myself about a dozen times to be careful, I somehow managed to forget to edit that part again. So now I had written two separate H&P's on this woman referring to her as a "pleasant Somoan gentleman."
In summary, sometimes it's better not to use a template.
that was too funny =) Good way to start an early morning. Thank You!
ReplyDeleteWhat are the odds this would happen to the same lady twice? Did she come to know of this? That would really top this story lol
ReplyDeleteThat's priceless Fizzy.
ReplyDeleteHaha, that sounds like something I would do, our EMR has smart phrases where these templates are already set and all we have to do is type in the personal info
ReplyDeleteI've done this with my abbreviation expansions as a transcriptionist. I once typed in "ftu" instead of fetus and the program expanded it to "feeding tube" -- and of course I didn't catch it. Fortunately the doc was amused rather than irate to read that he had dictated about a patient's 20-week feeding tube. (Not to mention the patient with a 6 m kidney -- always read what you write!) -- littlefoot
ReplyDeleteIf it's in the chart once, it's a typo. If it's there twice, it must be true.
ReplyDeleteSo, this lady is going to have to become a Pleasant Samoan Gentleman for the rest of the time she's seen at the VA!
This cracked me up! :)
ReplyDeleteI am currently a science undergrad doing research in a hospital. I have seen many instances of exactly what you have described: physicians seem to be using a template when summarizing a patient's history and present illness, and they accidentally refer to a boy as a girl, and a girl as a boy! It's so obvious that they didn't proofread the entire document before e-signing it.
i can't explain why, but this one touched a nerve. cannot. stop. laughing.
ReplyDeletethanks.
Also made me laugh.
ReplyDeleteAlso happens to lawyers, a lot. Had a client say to me "should this letter that's addressed to me say Dear *someone else*?"
Ah Fizzy, you certainly did it in style!
ReplyDeleteDon't you also find it amusing how we doctors write these 'social commentaries', or sometimes euphemisms (!!) to describe patients in our notes?
A typical one for me is "Thank you for seeing Mrs X, a pleasantly chatty lady of 87 years..." - this means "Ask direct questions if you have time constraints." Another classic is "Patient is a poor historian..." which translates to "I have no real idea of what the patient is saying. His/her account of symptoms does not make medical sense, but I don't want to write that down." Or "Patient denies excessive alcohol use..." infers suspicion and directs our colleague to further specific questioning.
Take-home message: in exchange for all those clues, let's overlook the occasional "pleasantly Samoan" slip-up! Imagine we left all those helpful descriptive bits out?