In residency, it seemed like often attendings have a lot of opinions about how specific things should be done and then make the same mistakes themselves.
For example, I got yelled at once because I forgot to put the date and time on one of my progress notes. This was apparently a really serious mistake (OK, I know it's a JCAHO violation), although the attending who spotted it didn't bother to fix it when she saw it. She said that I had to go back and fix it, except... get this, she couldn't remember the approximate date that the note was written or which patient it was. So she wanted me to look through every single patient's chart to find this note with no date.
So while I was searching through one patient's chart while the attending was writing her note, I found no less than TEN notes written by the attending with no date OR time. Naturally, I couldn't keep my mouth shut about it. As I fixed each one, I kept saying, "Look! Here's another one you didn't write the date on!" All I got was an, "Oops." There were also about half a dozen notes from consultants that were lacking the date and time.
ah you poor souls reduced to todys document and cya world. When I first started out, the first chart I looked read, "knee does not look good and neither does the patient"
ReplyDeleteXDDD Awesome. Sad, but awesome. Was it true, at least?
DeleteI have to review charts quite often in my job as a forensic pathologist. Not having a date and time listed can make interpretation of things quite hard. If push ever came to shove, I would have no problem throwing the note-writer under the bus for such a thing. Documentation is a huge (albeit boring) part of medicine. Period.
ReplyDeleteThat wasn't my point so much as the fact that I got called out for doing something wrong that the attending had done a dozen times.
DeleteAs a pharmacist, it's my job, pretty much, to bitch at people for not ordering stuff correctly. When I have to order something myself, I generally screw up for one of the ticky things that I would call them about. The nurses love to call me out on it. Now that we've switched to CPOE, it's not as easy to screw up on those stupid little things.
ReplyDeleteWe went through a big ordeal where we called on every order sheet without allergies written on it, and we would get bitched at by admin if they caught us processing orders without allergies. I felt like a douche for calling on every order, and even more of a douche when every order I sent, I forget to write allergies on the top of the page (of course, the nurses would make me run back down and write them in, because I would make them do the same before processing their orders). At least CPOE eliminates some of that stupid crap.
We still use paper charting, with new orders put in the front of the chart and old orders put in the back. We currently have one resident who doesn't date/time new orders, nor does he pay attention to WHERE he's writing orders... so, if it's February 18th, he may write new orders in the section for February 10th... no date, no time written, so who knows when it was written (and who even notices it in the back of the chart?). It's annoying and dangerous.
ReplyDelete