Nursing Frustrations

[DoctorJDO]

I find myself getting constantly annoyed by the nurses at my job.

Constant spelling errors. "Patient can't pea", "Tibial Platto fracture", all caps " AIRBAG DEPLOID"

Confusing left and right. No, the patient did no injure his left ankle, it was his right. Be more careful.

Documenting incorrect vitals. 79% room air sat at least once a day when that was actually the heart rate. Oopsies, silly me!

Charting seemingly irrelevant details: "patient hungry, will ask doctor if she can eat", or "administered zofran per patient's request". yeah, we know, you also documented that you gave the med in the MAR. What is the purpose of documenting it additionally in prose? couldn't you, IDK, be getting me a urine instead or something more useful?

Mis-triaging every other patient. No, they are not an ESI 1/2 because their blood pressure is elevated. They have tooth pain. Don't put them in a room and make the 80yo with belly pain wait to be seen behind tooth guy

I feel like I always try so hard to be better and improve. Learn from each encounter and improve my craft...Meanwhile the 40 year experience RN asks me EVERY DAY, Dr. X, are you sure you want to discharge the patient - their BP is 160/95. Yes, carol, my answer and every doctor's answer for the past 10 years and the last 3,500 times you have asked that question has been Yes, IDFC. We have presented and explained the ACEP policy to you many times and I can only assume at this point that you either have dementia and should no longer be a nurse, or you just don't care about your job or patients or my sanity. "MD notified of high blood pressure, no new orders at this time". Am I the only one at work who cares?

I get that they have their skillset and different training but it's frustrating having to be so perfect all the time and not miss anything and yet I'm just inundated with this slop all day. I can't tell if I have terrible nurses, or maybe I just didn't have enough experience in residency so I didn't pay attention to what the nurses were doing because I was more focused on my own learning.

Does anyone else deal with this?

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[Mr. Vandemar]

Yes. Every day, all day.

 

[bravotwozero]

Not documenting vitals or taking forever to put them in is my #1 pet peeve about nurses.

They’ve literally held up patient discharges because vitals weren’t documented by the time I’m actually ready to send patients home

 

[Neopolymath]

Documenting vitals as on room air that are not. So, so common. And why is the person doing the triage CC always typing in all caps with every other word being a typo?!

 

[e30ftw]

At this point I’m just glad when there are enough nurses to actually staff the ER and forget about the little things like vital signs or fluids for sepsis.

 

[southerndoc]

One of the funniest things I've seen documented in a chart was something to the effect "Patient's hypertension treated to stop the nursing requests for my sanity." I almost snorted my soda when I read that going through a patient's chart. Sadly, that doc has since retired. I used to love reading his notes. Nurses would put something in the comments section on the trackboard and he would respond with "don't care." Once I saw a "waaaaaa" in response to a patient stating that the morphine wasn't helping (drug-seeker patient).

 

[GassYous]

One time I was looking at an l&d patients chart and it was a block of notes by the same nurse. She was putting down some bs every three minutes. But when she called for a labor epidural, no supplies or anything useful in sight.

 

[RustedFox]

1.) Sounds like your nurses are awful.

2.) If you cannot spell in your native language, then I have serious reservations if you can read. If you can't read...

 

[EthylMethylMan]

The other day I had a lady bleeding out her rectum with MAP of 60 and altered mental status. Not one, but two nurses, one of them being the charge, asked me if I was sure that I wanted them to give the ED's O-negative blood. And not in a, "just confirming" way, but a "this doesn't make sense to me" way. One attempted to justify it with, "well, there's a blood shortage."

Another time recently I ordered basics and a troponin for an obese guy with chest pain and dyspnea. After an hour they weren't drawn so I ask the nurse if he'll be able to get around to it promptly. The guy actually yelled at me, demanding I not "nickel and dime" him. I attempted to explain that I get that everyone's busy and was not trying to be a jerk, but of course he didn't even let me finish the thought before continuing his tantrum.

And lest we forget, the countless times nurses will moan and groan about what they deem an excessive workup. "C'mon, just discharge the [insert chief complaint] guy, he looks fine." "I don't care that it's only been 3 minutes since the B52, let's just give more sedation!" "That chemically sedated guy doesn't need capno, are you serious?" When it's your license on the line, I'll start caring about what you think is excessive.

 

[bravotwozero]

Pelvic exam setup.

How many pelvic exams does someone need to see to realize that when I say I'm going to need a pelvic setup, that the patient needs to be in a gown and told to have undergarments off, the speculum and lube and swabs need to be at bedside, patient needs to be positioned, BEFORE I am told 'hey doc she's all ready' and absolutely none of the above mentioned things has happened?

 

[thegenius]

Pelvic exam setup.

How many pelvic exams does someone need to see to realize that when I say I'm going to need a pelvic setup, that the patient needs to be in a gown and told to have undergarments off, the speculum and lube and swabs need to be at bedside, patient needs to be positioned, BEFORE I am told 'hey doc she's all ready' and absolutely none of the above mentioned things has happened?

Apparently not enough times.

Perhaps 450?

 

[Groove]

I find myself getting constantly annoyed by the nurses at my job.

Constant spelling errors. "Patient can't pea", "Tibial Platto fracture", all caps " AIRBAG DEPLOID"

Confusing left and right. No, the patient did no injure his left ankle, it was his right. Be more careful.

Documenting incorrect vitals. 79% room air sat at least once a day when that was actually the heart rate. Oopsies, silly me!

Charting seemingly irrelevant details: "patient hungry, will ask doctor if she can eat", or "administered zofran per patient's request". yeah, we know, you also documented that you gave the med in the MAR. What is the purpose of documenting it additionally in prose? couldn't you, IDK, be getting me a urine instead or something more useful?

Mis-triaging every other patient. No, they are not an ESI 1/2 because their blood pressure is elevated. They have tooth pain. Don't put them in a room and make the 80yo with belly pain wait to be seen behind tooth guy

I feel like I always try so hard to be better and improve. Learn from each encounter and improve my craft...Meanwhile the 40 year experience RN asks me EVERY DAY, Dr. X, are you sure you want to discharge the patient - their BP is 160/95. Yes, carol, my answer and every doctor's answer for the past 10 years and the last 3,500 times you have asked that question has been Yes, IDFC. We have presented and explained the ACEP policy to you many times and I can only assume at this point that you either have dementia and should no longer be a nurse, or you just don't care about your job or patients or my sanity. "MD notified of high blood pressure, no new orders at this time". Am I the only one at work who cares?

I get that they have their skillset and different training but it's frustrating having to be so perfect all the time and not miss anything and yet I'm just inundated with this slop all day. I can't tell if I have terrible nurses, or maybe I just didn't have enough experience in residency so I didn't pay attention to what the nurses were doing because I was more focused on my own learning.

Does anyone else deal with this?

I used to really hook into nursing errors, laziness, attitude problems and incompetency. Great nurses wanted to work with me and the lazy ones hated working with me. I voiced my frustrations often and openly and made a lot of nursing enemies during those few years. Part of it had to do with the fact that I worked in a 100% RVU system and was heavily motivated to move the meat and if there were delays...would get incredibly frustrated because my paycheck was on the line. After a few years, (and a few gray hairs?) I finally learned to mellow out and detach from the things outside of my control. Nursing truly does have a difficulty job and even more so in today's current conditions. Nursing can also really make your life uncomfortable if they set their mind to it. During my first few years, I generated nursing complaints, occasional peer reviews while working in a hospital system where a malignant nursing culture encouraged such behavior. I had a few nurses that downright hated me. Although I never really got into trouble from any complaints, it was a headache having to explain yourself to chain of command. After awhile, you start to get the feeling that people are laying a paper trail to show perceived personality problems which can always be used to fire you. Nursing management would always say "nurses are afraid of you...intimidated by you, etc.." and even though I wasn't yelling at anyone or doing anything overtly antagonistic...it was still a headache.

In the end, I learned to relax...detach, chill out and am willing to overlook a few things unless pt safety is at stake. Nowadays, almost all nurses love working with me and I'm a very laid back and cool physician who almost never gets upset. Life is much easier these days and I wish I could go back and explain a few things to my younger self so that my life back then wouldn't have been quite as difficult.

I guess what I'm trying to say is that I hear you and empathize with you. Yes, we are held to a certain standard of excellence and are perfectionistic and obsessive compulsive by nature. However, nurses are not held to the same standard. It's also, in my experience, a futile effort to go out of your way attempting to "improve nurses" to your standard of excellence. You have virtually no power over them whatsoever as they answer to nursing chain of command. In most CMGs, it's even more of a problem as you are ultimately an IC physician generating a complaint about a nursing hospital employee. They also can, and will, make your life very difficulty if you go out of your way to get on their bad side. I can say that with experience. It's truly not worth the effort. I reserve any major complaints or castigations these days for situations where pt safety is on the line.

By the same token, I got some good advice from a great medical director (mentor) one time who told me "Groove...if you ever need to make a complaint about nursing or physician behavior, etc.. make it about "patient safety". Making it about you being angry that another person did something is perceived as petty and personal and can be ignored. Making it about patient safety increases the chances that someone will make a change or address the issue. You can ignore personal squabbles but it's more difficult to ignore patient safety concerns." It was good advice and any complaints I've made in the past few years, I try to formulate around a concern for pt safety which tends to get more attention than a complaint about individual behavioral issues.

 

[southerndoc]

Pelvic exam setup.

How many pelvic exams does someone need to see to realize that when I say I'm going to need a pelvic setup, that the patient needs to be in a gown and told to have undergarments off, the speculum and lube and swabs need to be at bedside, patient needs to be positioned, BEFORE I am told 'hey doc she's all ready' and absolutely none of the above mentioned things has happened?

New techs take a hint after one or two times I walk into the room with them to chaperone and the patient is still dressed. I tell them "call me when you're really set up" and leave the room.

 

[Groove]

The problem is that nurses are in such high demand these days that they can get away with any amount of egregious behavior. Unlike physicians...

 

[lymphocyte]

I used to really hook into nursing errors, laziness, attitude problems and incompetency. Great nurses wanted to work with me and the lazy ones hated working with me. I voiced my frustrations often and openly and made a lot of nursing enemies during those few years. Part of it had to do with the fact that I worked in a 100% RVU system and was heavily motivated to move the meat and if there were delays...would get incredibly frustrated because my paycheck was on the line. After a few years, (and a few gray hairs?) I finally learned to mellow out and detach from the things outside of my control. Nursing truly does have a difficulty job and even more so in today's current conditions. Nursing can also really make your life uncomfortable if they set their mind to it. During my first few years, I generated nursing complaints, occasional peer reviews while working in a hospital system where a malignant nursing culture encouraged such behavior. I had a few nurses that downright hated me. Although I never really got into trouble from any complaints, it was a headache having to explain yourself to chain of command. After awhile, you start to get the feeling that people are laying a paper trail to show perceived personality problems which can always be used to fire you. Nursing management would always say "nurses are afraid of you...intimidated by you, etc.." and even though I wasn't yelling at anyone or doing anything overtly antagonistic...it was still a headache.

In the end, I learned to relax...detach, chill out and am willing to overlook a few things unless pt safety is at stake. Nowadays, almost all nurses love working with me and I'm a very laid back and cool physician who almost never gets upset. Life is much easier these days and I wish I could go back and explain a few things to my younger self so that my life back then wouldn't have been quite as difficult.

I guess what I'm trying to say is that I hear you and empathize with you. Yes, we are held to a certain standard of excellence and are perfectionistic and obsessive compulsive by nature. However, nurses are not held to the same standard. It's also, in my experience, a futile effort to go out of your way attempting to "improve nurses" to your standard of excellence. You have virtually no power over them whatsoever as they answer to nursing chain of command. In most CMGs, it's even more of a problem as you are ultimately an IC physician generating a complaint about a nursing hospital employee. They also can, and will, make your life very difficulty if you go out of your way to get on their bad side. I can say that with experience. It's truly not worth the effort. I reserve any major complaints or castigations these days for situations where pt safety is on the line.

By the same token, I got some good advice from a great medical director (mentor) one time who told me "Groove...if you ever need to make a complaint about nursing or physician behavior, etc.. make it about "patient safety". Making it about you being angry that another person did something is perceived as petty and personal and can be ignored. Making it about patient safety increases the chances that someone will make a change or address the issue. You can ignore personal squabbles but it's more difficult to ignore patient safety concerns." It was good advice and any complaints I've made in the past few years, I try to formulate around a concern for pt safety which tends to get more attention than a complaint about individual behavioral issues.

There's a lot of wisdom in this post.

 

[GonnaBeADoc2222]

I get a long great with "old school" type nurses with a "let's get this done" attitude that can handle situations on their own without hand holding.

I get along poorly with nurses who try to overstep, practice medicine without a license, and need me to talk to the patient at the drop of a hat 8x during a visit.

I've gotten compliments from the former, and complaints from the latter.

Don't care anymore.

 

[ProwlerturnGas]

I’m curious so maybe someone knows. Why do ED nurses feel the need to document every little thing in Epic? I’ll often see 12 different epic notes while the patient is in the ED such as:
Dr X examine patient
Dr Y doing preop eval
Nurse R starting IV
Patient getting undressed
And so on…

Each episode it’s own note and the only nurses in the hospital that do that from what I can tell ?

I

 

[Fox800]

How about I'm CLEARLY in the middle of interviewing my patient, and the RN steps up and shoves a thermometer in their mouth. So you just awkwardly interrupted my interview for 30 seconds and I sit there tapping my foot. Thanks. Very considerate.

 

[NITRAS]

I’m curious so maybe someone knows. Why do ED nurses feel the need to document every little thing in Epic? I’ll often see 12 different epic notes while the patient is in the ED such as:
Dr X examine patient
Dr Y doing preop eval
Nurse R starting IV
Patient getting undressed
And so on…

Each episode it’s own note and the only nurses in the hospital that do that from what I can tell ?

I

Funny thing, on the floor, the nurses notes are totally useless. :
Patient pain, progressing,

Patient oxygenation, progressing,

I don’t care. I much prefer the notes in ED. “ Daughter said she got tired of taking care of grandma because she has a trip to go to” is so much more helpful.

 

[emergentmd]

This may sound bad but I look vital signs and almost never read the nurses notes. They write stuff that makes our job harder, makes me have to defend my workup, etc.

My choice is spend 2-3 min reading their notes, asking them to correct it, sound like a helicopter doc, and then alienate the staff vs never reading it making my shift so much easier.

I pick the later for the past 20 years and never had an issue. Maybe Russian roulette, but even if I got a lawsuit it would have been better than the countless time/stress/unintended fractured relationships. I am sure not many really read through most/all of the notes or it would drive them crazy.

I am sure if people looked at my charts, they would think I was incompetent half the time b/c I really do not write everything the patient states.

That 20 yr old with no medical issues having chest pressure and radiation never goes onto my chart.

 

[RustedFox]

This may sound bad but I look vital signs and almost never read the nurses notes. They write stuff that makes our job harder, makes me have to defend my workup, etc.

My choice is spend 2-3 min reading their notes, asking them to correct it, sound like a helicopter doc, and then alienate the staff vs never reading it making my shift so much easier.

I pick the later for the past 20 years and never had an issue. Maybe Russian roulette, but even if I got a lawsuit it would have been better than the countless time/stress/unintended fractured relationships. I am sure not many really read through most/all of the notes or it would drive them crazy.

I am sure if people looked at my charts, they would think I was incompetent half the time b/c I really do not write everything the patient states.

That 20 yr old with no medical issues having chest pressure and radiation never goes onto my chart.

The term for this is "pan-positive ROS".

 

[Zebra Hunter]

That 20 yr old with no medical issues having chest pressure and radiation never goes onto my chart.

As my favorite attending in residency used to ask all the interns he worked with for the first time, "Should your documentation reflect exactly what was stated by the patient and what happened in the ER?"

"Yes?"

"No you ****ing idiot. Charts are for billing and protecting your *** legally." This was usually followed by "If you aren't going to get a CT scan on a patient with abdominal pain, don't be the idiot that documents that they were tender on exam."

 

[d2305]

Even NPs don't answer to the Board of Medicine. They have their own board without a single physician on it.

 

[Neopolymath]

The term for this is "pan-positive ROS".

This was one of my reasons for not pursuing EM. That and the American, English first and only language speaking patients who tell you they have chest pain but they really have anything else but chest pain. I came to realize a lot of patients at my hospital were either too stupid or unable to speak at the kindergarten level to tell you what was going on in the ED and it made me so mad. They absolutely weren't malingering. The pain wasn't radiating. It wasn't a failure of history taking and an inability to get the nuanced details from a confused patient. They would say they have chest pain and then point to their bruised back, throat or their belly button. It was a failure to adult of the most basic kind. I'm getting irritated just making this post haha.

My all time favorite was my patient complaining of belly pain but when asked to describe said it didn't hurt and was just really itchy. I asked what it felt like and to charactize the pain and she denied every adjective I could muster to describe any type of pain in existence and said it was pruritis. So I said, you told me you have a belly ache but told me it doesn't hurt and only itch. She said, "yeah, that kind of belly ache." Once again, truly an inability to speak basic English in this case. Unbelievable.

 

[RustedFox]

This was one of my reasons for not pursuing EM. That and the American, English first and only language speaking patients who tell you they have chest pain but they really have anything else but chest pain. I came to realize a lot of patients at my hospital were either too stupid or unable to speak at the kindergarten level to tell you what was going on in the ED and it made me so mad. They absolutely weren't malingering. The pain wasn't radiating. It wasn't a failure of history taking and an inability to get the nuanced details from a confused patient. They would say they have chest pain and then point to their bruised back, throat or their belly button. It was a failure to adult of the most basic kind. I'm getting irritated just making this post haha.

Yep.
This is one of the most disheartening details about a career in EM. It leads quickly to burnout. Once you realize that the average American is so, SO dumb... TOO dumb to even participate in the reason for their visit... THEN the hate really begins to go from a slow burn to an open, accelerated fire.

The number one cause of burnout is...

 

[Matthew9Thirtyfive]

Yep.
This is one of the most disheartening details about a career in EM. It leads quickly to burnout. Once you realize that the average American is so, SO dumb... TOO dumb to even participate in the reason for their visit... THEN the hate really begins to go from a slow burn to an open, accelerated fire.

The number one cause of burnout is...

As the man once said, think about how dumb the average person is, then realize that half of them are dumber than that.

 

[emergentmd]

Americans are not generally dumb. We get the most ignorant/lazy subgroups that comes to the ER but not a true reflection of our society.

ER pts are typically the worse historian. I was told as a med student that pts history is the most important part of the encounter, which is categorically false and whoever tells you this have no clue about clinical medicine.

The most important part of my encounter is Past medical hx, vitals, and my finely tuned physical exam. History is essentially 3-5 short answer/yes/no questions.

Pts history is useless and the more history you take the most useless it is.

 

[turkeyjerky]

As my favorite attending in residency used to ask all the interns he worked with for the first time, "Should your documentation reflect exactly what was stated by the patient and what happened in the ER?"

"Yes?"

"No you ****ing idiot. Charts are for billing and protecting your *** legally." This was usually followed by "If you aren't going to get a CT scan on a patient with abdominal pain, don't be the idiot that documents that they were tender on exam."

This is so key. It really explains the frustration that so many people have w/ scribes. That and oftentimes writing nonsensical or misspelled words when the mishear what I say.

The frustrations in this thread seem so universal that you have to wonder about the underlying causes. Is it the way nurses are taught or do they just not understand how seriously we take VS and triage notes?

Just think of the difference between "Pt complains of back pain and cannot walk" vs "Pt presents with back pain, states they cannot walk but was seen ambulating from car w/o difficulty". The former leads to a bunch of defensive documentation, pain meds in the ED and getting the bedside nurse or tech to document a road test vs the latter which is basically an immediate d/c after H&P.

At my old shop, I used to flip my **** about patient's w/ back pain not being undressed. After the Nth time of going to a room, finding the patient still in their full length parka and 2 pairs of pants, then storming out to get them a gown while grumbling under my breath, a nurse asked me in a genuinely surprised tone if I wanted all patient's w/ back pain undressed. It turns out that the nursing director had been telling them to keep all FT patients fully dressed in an effort to improve d/c times.

 

[Matthew9Thirtyfive]

ER pts are typically the worse historian. I was told as a med student that pts history is the most important part of the encounter, which is categorically false and whoever tells you this have no clue about clinical medicine.

What? I mean I have only just completed my third year rotations, but in like 90% of cases the answer was in the history. Maybe it’s different in the ED.

 

[thegenius]

Can’t say, with due respect, that I agree with this. I’ve had countless encounters where history has led to a quick, appropriate, and safe disposition. That same encounter with another doctor would have led to a vast array of unneeded testing.

 

[Angry Birds]

Can’t say, with due respect, that I agree with this. I’ve had countless encounters where history has led to a quick, appropriate, and safe disposition. That same encounter with another doctor would have led to a vast array of unneeded testing.

On the whole though, such a method means probably seeing less patients as fast.

 

[emergentmd]

What? I mean I have only just completed my third year rotations, but in like 90% of cases the answer was in the history. Maybe it’s different in the ED.

Lets throw out all the nonsense that comes into the ER b/c no matter how long you talk to the pt, nothing really changes with them going home.

21 YO female with Chest pressure with left arm radiation, no medical hx, normal vitals. History has many cardiac qualities. She goes home no matter how many questions you ask.

65 YO old with risk factors, and a decent story. They will likely get admitted no matter how many questions I ask.

You can either spend 10 minutes talking to them or spend 2 min then moving onto the next pt. You either will run an efficient ER or bog the ER down. You get to pick one.

After awhile you will figure out that asking pts too many questions is low yield.

 

[thegenius]

On the whole though, such a method means probably seeing less patients as fast.

Probably true…conceptually true. The reason why I’m in the top 1/3 efficiency (I’m somewhere between 5-8 out of a group of about 20) is I test less. Not markedly so. The average CT% is 23%. I’m 19%. My LOS is slightly lower. So there are efficiencies gained by spending a little more time with people.

 

[turkeyjerky]

On the whole though, such a method means probably seeing less patients as fast.

Depends on the rate limiting step. If it's beds, lab, nurses, imaging, etc then it's faster to take an appropriate h+p. If it's simply physician time and the rest are always in good supply at your shop, then order away.

 

[emergentmd]

Can’t say, with due respect, that I agree with this. I’ve had countless encounters where history has led to a quick, appropriate, and safe disposition. That same encounter with another doctor would have led to a vast array of unneeded testing

99% of the pts all docs no matter the amount of questions asked will have the same disposition. The other 1% is what makes a good ER doc. Some takes a long time to figure who the 1% is, some do it quickly in their career, some never figure it out.

I can spot that 1%, probably 95% of the time. I may miss the other 5% but that is just the nature of the job. Of those 5%, most will not have a bad outcome.

I would guess that I have seen 100K pts in my 20 yr career and never had a Lawsuit come out of an Er pt. To my knowledge, I have never had a bad outcome return that would have changed what I did. I am sure I have had many pts return that I did not diagnose correctly, but my job is not to get 100% diagnoses correct.

Everyone just needs to find what makes them comfortable. Working in the hospital ERs for 17 years, I was either #1 or 2 in efficiency measured by pph or LOS. I definitely spent the least amount of time staying back to finish up my shifts.

 

[RustedFox]

This is so key. It really explains the frustration that so many people have w/ scribes. That and oftentimes writing nonsensical or misspelled words when the mishear what I say.

Do you guys remember the thread that I started several years ago entitled something like: "Do Your Scribes Suck?"

- and all the students and kiddies got pissy because the scribes couldn't take criticism and cried and snowflaked about?

It has been several years. I wonder how those students feel now, if they're into their residencies and beyond.

 

[CajunMedic]

Our worst offender finally left and took a full-time job in correctional nursing. They hadn't spoken 3 words to me since I dared challenge their authority. At least I don't have to listen to them loudly describe their sexual escapades in great detail anymore.

 

[Matthew9Thirtyfive]

Our worst offender finally left and took a full-time job in correctional nursing. They hadn't spoken 3 words to me since I dared challenge their authority. At least I don't have to listen to them loudly describe their sexual escapades in great detail anymore.

Sounds like you could have threatened a sexual harassment suit. (Guessing you’re IC and can’t actually do that.)

 

[CajunMedic]

Sounds like you could have threatened a sexual harassment suit. (Guessing you’re IC and can’t actually do that.)

Still a Resident. Seriously thought about an anonymous report, figured it wouldn't go anywhere. The one time I filed a patient safety report on a nurse, I got a polite "Our nurses can do no wrong" email.

 

[Matthew9Thirtyfive]

Still a Resident. Seriously thought about an anonymous report, figured it wouldn't go anywhere. The one time I filed a patient safety report on a nurse, I got a polite "Our nurses can do no wrong" email.

Gross. What a terrible culture.

 

[bingbongbink]

Americans are not generally dumb. We get the most ignorant/lazy subgroups that comes to the ER but not a true reflection of our society.

ER pts are typically the worse historian. I was told as a med student that pts history is the most important part of the encounter, which is categorically false and whoever tells you this have no clue about clinical medicine.

The most important part of my encounter is Past medical hx, vitals, and my finely tuned physical exam. History is essentially 3-5 short answer/yes/no questions.

Pts history is useless and the more history you take the most useless it is.

Not EM so don’t work in the ED setting but CCM. Agree with this so much. Focused histories do help, but you can’t linger. And would like to add, a reconciled med list, or a helpful family member can give much better collateral you can piece together so much history rather spending 15 minutes trying to get a story out of the patient who isn’t really listening.

 

[bingbongbink]

Sounds like you could have threatened a sexual harassment suit. (Guessing you’re IC and can’t actually do that.)

What is IC?

 

[The Knife & Gun Club]

Pelvic exam setup.

How many pelvic exams does someone need to see to realize that when I say I'm going to need a pelvic setup, that the patient needs to be in a gown and told to have undergarments off, the speculum and lube and swabs need to be at bedside, patient needs to be positioned, BEFORE I am told 'hey doc she's all ready' and absolutely none of the above mentioned things has happened?

You guys have nurses helping you with pelvics?!

I kid, but at our county shop if I ask a nurse to help with pelvic setup they snort-laugh and tell me to get the supplies from the closet and charge them to the patient, gown the patient, and tell them when I’m ready and they’ll come in and observe. It’s excruciating.

 

[emergentmd]

We had scribes at one of my old shops, which helped a lot. Prob saved me 2 hrs of charting.

Kept hearing constant complaints from a few docs that they spent more time reading/correcting the scribe charts than just doing it themselves. One guy even asked not to have scribes.

The scribe works for you, so you tell them what to do. When I have a new scribe, I tell them.

1. Chart what I tell you, not what the pt says.
2. All Physical exams are normal unless I tell you a positive. I give them a "normal exam template"
3. Never put a positive finding unless I tell you.

Some scribes didn't even follow me sometimes. I just walk out of the room, give the scribes a one sentence blurb such as

"25 yr old male, no risk factors/healthy, with sharp chest pain worse with movements. All other ROS neg"
Physical - 100% reproducible CP. everything else neg

Done, and chart essentially what I would write for a guy I am sending home.

Docs let scribes write what the pt says, and ends up with "25 YO with heavy chest pain, mid sternal, worse with walking". I do not want to work up 10 complaints b/c the pt complained of a HA, CP, Abd pain, rash, SOB, diarrhea, cough, dark stool, confusion, eye pain, blurry vision, vertigo. Pts get to have 1 complaint worked up and maybe 2 if they come across as legit.

Scribes usefulness is to document to the correct level 4/5, relieve me of 2 min pp clicking/making notes, telling me when my labs/imaging is ready, and finding the nurse to get me something.

That is it. They are no use following me in the pt room b/c what the pt says is not what I want on the chart.

 

[Mount Asclepius]

We had scribes at one of my old shops, which helped a lot. Prob saved me 2 hrs of charting.

Kept hearing constant complaints from a few docs that they spent more time reading/correcting the scribe charts than just doing it themselves. One guy even asked not to have scribes.

The scribe works for you, so you tell them what to do. When I have a new scribe, I tell them.

1. Chart what I tell you, not what the pt says.
2. All Physical exams are normal unless I tell you a positive. I give them a "normal exam template"
3. Never put a positive finding unless I tell you.

Some scribes didn't even follow me sometimes. I just walk out of the room, give the scribes a one sentence blurb such as

"25 yr old male, no risk factors/healthy, with sharp chest pain worse with movements. All other ROS neg"
Physical - 100% reproducible CP. everything else neg

Done, and chart essentially what I would write for a guy I am sending home.

Docs let scribes write what the pt says, and ends up with "25 YO with heavy chest pain, mid sternal, worse with walking". I do not want to work up 10 complaints b/c the pt complained of a HA, CP, Abd pain, rash, SOB, diarrhea, cough, dark stool, confusion, eye pain, blurry vision, vertigo. Pts get to have 1 complaint worked up and maybe 2 if they come across as legit.

Scribes usefulness is to document to the correct level 4/5, relieve me of 2 min pp clicking/making notes, telling me when my labs/imaging is ready, and finding the nurse to get me something.

That is it. They are no use following me in the pt room b/c what the pt says is not what I want on the chart.

You’ve lost your sense of ethics and will have to live with your own conscious. I hear what you’re saying regarding defensive charting, but being so fearful of a lawsuit doesn’t gain you anything when you straight lie. Lawsuits aren’t about you or your ability. Just wait until someone records your encounter and it drastically conflicts with your chart. You’re better off just practicing good medicine and realizing that the system is flawed. I don’t worry when a young person has “crushing” chest pain when they are low risk and have completely negative testing. I sleep well at night knowing I practiced good medicine and didn’t compromise my sense of right.

 

[NYEMMED]

You’ve lost your sense of ethics and will have to live with your own conscious. I hear what you’re saying regarding defensive charting, but being so fearful of a lawsuit doesn’t gain you anything when you straight lie. Lawsuits aren’t about you or your ability. Just wait until someone records your encounter and it drastically conflicts with your chart. You’re better off just practicing good medicine and realizing that the system is flawed. I don’t worry when a young person has “crushing” chest pain when they are low risk and have completely negative testing. I sleep well at night knowing I practiced good medicine and didn’t compromise my sense of right.

You do this long enough and you learn one thing.

Good medicine means nothing, good charts mean everything.

 

[skougess]

You’ve lost your sense of ethics and will have to live with your own conscious. I hear what you’re saying regarding defensive charting, but being so fearful of a lawsuit doesn’t gain you anything when you straight lie. Lawsuits aren’t about you or your ability. Just wait until someone records your encounter and it drastically conflicts with your chart. You’re better off just practicing good medicine and realizing that the system is flawed. I don’t worry when a young person has “crushing” chest pain when they are low risk and have completely negative testing. I sleep well at night knowing I practiced good medicine and didn’t compromise my sense of right.

Highly disagree. If my chart doesn’t reflect my eventual MDM then I either need to change my chart or change my management. The latter does happen sometimes when I go back over things objectively. However, including extraneous things in the chart (i.e. severe chest pain on the 18 yo URI with no sign of myocarditis) does nothing to help the patient and everything to potentially hurt you as the physician.

 

[RustedFox]

We had scribes at one of my old shops, which helped a lot. Prob saved me 2 hrs of charting.

Kept hearing constant complaints from a few docs that they spent more time reading/correcting the scribe charts than just doing it themselves. One guy even asked not to have scribes.

The scribe works for you, so you tell them what to do. When I have a new scribe, I tell them.

1. Chart what I tell you, not what the pt says.
2. All Physical exams are normal unless I tell you a positive. I give them a "normal exam template"
3. Never put a positive finding unless I tell you.

Some scribes didn't even follow me sometimes. I just walk out of the room, give the scribes a one sentence blurb such as

"25 yr old male, no risk factors/healthy, with sharp chest pain worse with movements. All other ROS neg"
Physical - 100% reproducible CP. everything else neg

Done, and chart essentially what I would write for a guy I am sending home.

Docs let scribes write what the pt says, and ends up with "25 YO with heavy chest pain, mid sternal, worse with walking". I do not want to work up 10 complaints b/c the pt complained of a HA, CP, Abd pain, rash, SOB, diarrhea, cough, dark stool, confusion, eye pain, blurry vision, vertigo. Pts get to have 1 complaint worked up and maybe 2 if they come across as legit.

Scribes usefulness is to document to the correct level 4/5, relieve me of 2 min pp clicking/making notes, telling me when my labs/imaging is ready, and finding the nurse to get me something.

That is it. They are no use following me in the pt room b/c what the pt says is not what I want on the chart.

See, no matter how many times I said to the scribes: "You type exactly what I tell you to type and nothing more", I still got creative writing projects as charts. They were so bad across the board that they're no longer used.

 

[RustedFox]

Just wait until someone records your encounter and it drastically conflicts with your chart.

Check the recording laws in your state. Doing so without consent can be very criminal.

 

[GassYous]

You’ve lost your sense of ethics and will have to live with your own conscious. I hear what you’re saying regarding defensive charting, but being so fearful of a lawsuit doesn’t gain you anything when you straight lie. Lawsuits aren’t about you or your ability. Just wait until someone records your encounter and it drastically conflicts with your chart. You’re better off just practicing good medicine and realizing that the system is flawed. I don’t worry when a young person has “crushing” chest pain when they are low risk and have completely negative testing. I sleep well at night knowing I practiced good medicine and didn’t compromise my sense of right.

Riiight. That's why when the druggies come through with their 15/10 chest pain, I chart that they have 15/10 chest pain and give them dilaudid + benadryl chaser (due to their pruritus) as well as a cath.