Nursing Frustrations

[Apollyon]

What is IC?

Independent contractor. 1099 worker, not W-2 employee.

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[DrSnips]

Can anyone summarize House of God in one sentence?

Good medicine means nothing, good charts mean everything.

 

[Matthew9Thirtyfive]

Can anyone summarize House of God in one sentence?

Good medicine means nothing, good charts and call room sex mean everything.

FTFY.

 

[BoardingDoc]

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

"Eleven states require two-party consent. In other words, everyone involved in a conversation must agree to be recorded. Those states are, California, Delaware, Florida, Illinois, Maryland, Massachusetts, Montana, Nevada, New Hampshire, Pennsylvania and Washington."

 

[wholeheartedly]

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.

But aren’t you only in trouble if that piece of information like chest pain later turns out to be relevant?

Then you’ve screwed the patient. There’s got to be a balance point somewhere.

 

[Mount Asclepius]

Negative trops and dimers (if indicated) in 20 year olds with chest pain, no matter how described, matter more than lying in a chart. I’m not saying you have to include every detail, but if they say it’s pressure and you chart sharp, or if it’s not reproducible and you say it is, that’s just plain lying, wrong, and if you get caught can get burned. You do try to make everything fit your disposition. You don’t have to give Dilaudid and do a cath for severe meth gastritis/GERD. You do what’s right for the patient even if it’s not what they necessarily always want.

Most of us live in states where patients can record you without you knowing and can access their own chart. You do this long enough and you realize some things change.

 

[turkeyjerky]

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

Several years ago I got a complaint from a patient which was frankly bizarre, but she claimed to have recording of our conversation. It was with great satisfaction that I responded to admin that if she had recorded, it was without my consent and I intended to press charges.

 

[thegenius]

In my opinion scribes are a net positive. I can see more patients and work less. You can tell them what you want and don't want to chart.

Docs that are so particular about what goes into the chart are too worried about litigation. We all are to a degree...but it can get excessive. Especially since most lawsuits have nothing to do about patient care or medical workup anyway. So it matters not what you write. TH once told us there is a lawsuit per 40,000 patient encounters (would love to verify that...but it passes the "makes sense" test). I'm not going to be spending more than a minute charting to protect myself against those odds.

What I do is determine if a chart is low or high risk for litigation. >95% of charts are low risk, or low to medium risk. I don't do much with them. My MDM is the single most important thing. If there are discrepancies and I'm on the stand, then I'll say what's in my MDM as it's my interpretation of the facts and complaints.

Personally I don't really care what goes in the HPI 98% of the time. The patient can say anything they want. They can say they have HA, chest pain, abd pain, frogs coming out of their ass, fever, malaise, and anything else. They can say they were abducted by aliens and ended up on Pluto and were poked and prodded in various orifices and then were transported back to earth. "Doc is this why I'm pooping blood?" I'll document what they say. It doesn't matter. What matters is my interpretation of their complaints, their physical, vitals and any ancillary testing to determing if they have a medical emergency.

Occasionally, and I mean rarely, I'll pad it or change their story depending on what's being said.

I do agree that if you document something is "tender" and don't do any imaging or anything else, you need to justify why. Not all tenderness needs a workup.



Also, the only reason to put more in the HPI than less is for billing. If you write in an HPI

"20 yo with no RF p/w chest pain worse with arm movement, none at rest. All other ROS neg."

This would probably be an ESI 4 (99204) but not the way it's documented. So it would be downcoded to a 3 and you miss out on $$. So you can either lie and put in a more thorough ROS and history and what not, or just ask a few more questions which at least gives the appearance that you care.

 

[thegenius]

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

What if a patient surreptitiously has their phone on while talking to you, and someone else is listening on your conversation. But there is no recording. Is that illegal? That happens to me about once/month.

 

[GassYous]

What if a patient surreptitiously has their phone on while talking to you, and someone else is listening on your conversation. But there is no recording. Is that illegal? That happens to me about once/month.

That's really fukin weird that's what that is

 

[emergentmd]

Negative trops and dimers (if indicated) in 20 year olds with chest pain, no matter how described, matter more than lying in a chart. I’m not saying you have to include every detail, but if they say it’s pressure and you chart sharp, or if it’s not reproducible and you say it is, that’s just plain lying, wrong, and if you get caught can get burned. You do try to make everything fit your disposition. You don’t have to give Dilaudid and do a cath for severe meth gastritis/GERD. You do what’s right for the patient even if it’s not what they necessarily always want.

Most of us live in states where patients can record you without you knowing and can access their own chart. You do this long enough and you realize some things change.

You do you. This has nothing to do with ethics or not doing what is right for the pt. I give pts good clinical care regardless of what I chart. Its not like I send every young chest pain home without any tests.

I bet my clinical care is probably just as good or better than yours. You do you but this has zero to do with good pt care and very little to do with ethics.

Young healthy 20 guy comes in with chest pain for the 5th time that is worse ever, crushing, heavy, worse with exertion.

Me - Atypical chart, neg previous work up, I order an EKG/CXR to rule out some weird pericarditis/PTX then DC him in 1 hr.

You - being the ethical doctor charts Crushing chest pain (your ethical remember), worse with exertion, worse pain ever.
Scenario #1 You order a cardiac work up, labs. maybe keep him in the ER for 3 hrs for another set of Trop. He leaves in 5 hrs with atypical CP.
Scenario #2 you D/c with little to zero workup. Dude goes home, shots up drugs, and found dead. Family/Lawyer gets your chart and dude clearly had cardiac angina and as an expert witness, I would tell the Jury that your chart clearly was cardiac angina. Essentially the pt told you he was having cardiac angina and you discharged him. Seems medically unethical to me.

Who do you think gave the pt better care? How are you any more ethical drawing labs for the 5th time and doing a chest pain rule out, or you D/C him without much of a work up for his cardiac story?

Let the ones who have not sinned throw the 1st stone. If you always chart what the pt states (remember you are completely ethical), then go ahead cast the stone. If not, you are just a hypocrite.

 

[emergentmd]

What if a patient surreptitiously has their phone on while talking to you, and someone else is listening on your conversation. But there is no recording. Is that illegal? That happens to me about once/month.

Unless they strap a microphone onto my and the pt, they will barely hear what I am saying. A buddy backing up what the pt says against a trained medical professional is like getting a felon testify for the state.

 

[dieABRdie]

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.

I remember in residency one of the nurses was complaining about the notes they have to write.

I said... "Nurses write notes?"

"Yes! You guys don't read them???"

"No...."

 

[lucid_leprechaun]

You do you. This has nothing to do with ethics or not doing what is right for the pt. I give pts good clinical care regardless of what I chart. Its not like I send every young chest pain home without any tests.

I bet my clinical care is probably just as good or better than yours. You do you but this has zero to do with good pt care and very little to do with ethics.

Young healthy 20 guy comes in with chest pain for the 5th time that is worse ever, crushing, heavy, worse with exertion.

Me - Atypical chart, neg previous work up, I order an EKG/CXR to rule out some weird pericarditis/PTX then DC him in 1 hr.

You - being the ethical doctor charts Crushing chest pain (your ethical remember), worse with exertion, worse pain ever.
Scenario #1 You order a cardiac work up, labs. maybe keep him in the ER for 3 hrs for another set of Trop. He leaves in 5 hrs with atypical CP.
Scenario #2 you D/c with little to zero workup. Dude goes home, shots up drugs, and found dead. Family/Lawyer gets your chart and dude clearly had cardiac angina and as an expert witness, I would tell the Jury that your chart clearly was cardiac angina. Essentially the pt told you he was having cardiac angina and you discharged him. Seems medically unethical to me.

Who do you think gave the pt better care? How are you any more ethical drawing labs for the 5th time and doing a chest pain rule out, or you D/C him without much of a work up for his cardiac story?

Let the ones who have not sinned throw the 1st stone. If you always chart what the pt states (remember you are completely ethical), then go ahead cast the stone. If not, you are just a hypocrite.

Might catch an atypical dissection or PE if you work it up. Young people can have pathology

 

[emergentmd]

Might catch an atypical dissection or PE if you work it up. Young people can have pathology

Again, I work up for young healthy zebras if my gestalt tells me to. Not all my Youngs get sent packing.

Someone coming in that looks like they are really in distress or look worrisome, I will CT their chest. But I am not doing this for the vast majority of young pts on the phones texting their friends.

 

[Mount Asclepius]

You do you. This has nothing to do with ethics or not doing what is right for the pt. I give pts good clinical care regardless of what I chart. Its not like I send every young chest pain home without any tests.

I bet my clinical care is probably just as good or better than yours. You do you but this has zero to do with good pt care and very little to do with ethics.

Young healthy 20 guy comes in with chest pain for the 5th time that is worse ever, crushing, heavy, worse with exertion.

Me - Atypical chart, neg previous work up, I order an EKG/CXR to rule out some weird pericarditis/PTX then DC him in 1 hr.

You - being the ethical doctor charts Crushing chest pain (your ethical remember), worse with exertion, worse pain ever.
Scenario #1 You order a cardiac work up, labs. maybe keep him in the ER for 3 hrs for another set of Trop. He leaves in 5 hrs with atypical CP.
Scenario #2 you D/c with little to zero workup. Dude goes home, shots up drugs, and found dead. Family/Lawyer gets your chart and dude clearly had cardiac angina and as an expert witness, I would tell the Jury that your chart clearly was cardiac angina. Essentially the pt told you he was having cardiac angina and you discharged him. Seems medically unethical to me.

Who do you think gave the pt better care? How are you any more ethical drawing labs for the 5th time and doing a chest pain rule out, or you D/C him without much of a work up for his cardiac story?

Let the ones who have not sinned throw the 1st stone. If you always chart what the pt states (remember you are completely ethical), then go ahead cast the stone. If not, you are just a hypocrite.

I don't change patient's words and write inaccurate things in patient's charts. I might be selective with my charting, but I'm not dishonest. In the age of body cameras, cell phones and frequent recording you are going to get burned. Trops x2 don't lie and I don't worry no matter how a patient describes their pain when their testing is negative.

Side comment: High sensitivity troponins are trended at 2 hours. No need for a 5 hour LOS for any CP patient.

 

[thegenius]

You do you. This has nothing to do with ethics or not doing what is right for the pt. I give pts good clinical care regardless of what I chart. Its not like I send every young chest pain home without any tests.

I bet my clinical care is probably just as good or better than yours. You do you but this has zero to do with good pt care and very little to do with ethics.

Young healthy 20 guy comes in with chest pain for the 5th time that is worse ever, crushing, heavy, worse with exertion.

Me - Atypical chart, neg previous work up, I order an EKG/CXR to rule out some weird pericarditis/PTX then DC him in 1 hr.

You - being the ethical doctor charts Crushing chest pain (your ethical remember), worse with exertion, worse pain ever.
Scenario #1 You order a cardiac work up, labs. maybe keep him in the ER for 3 hrs for another set of Trop. He leaves in 5 hrs with atypical CP.
Scenario #2 you D/c with little to zero workup. Dude goes home, shots up drugs, and found dead. Family/Lawyer gets your chart and dude clearly had cardiac angina and as an expert witness, I would tell the Jury that your chart clearly was cardiac angina. Essentially the pt told you he was having cardiac angina and you discharged him. Seems medically unethical to me.

Who do you think gave the pt better care? How are you any more ethical drawing labs for the 5th time and doing a chest pain rule out, or you D/C him without much of a work up for his cardiac story?

Let the ones who have not sinned throw the 1st stone. If you always chart what the pt states (remember you are completely ethical), then go ahead cast the stone. If not, you are just a hypocrite.

I think if your 20 yo with chest pain is discharged and dies a day later, nobody is going to care about what you charted. A lawyer will find you negligent, you will get sued and either lose in court or settle for 5-10M.

 

[Porfirio]

The truth is there is no standard of care with regard to chest pain. There are only bad out comes and plaintiffs that have a sad story for the jury. This is why settlement is best. Heart Scores are argued up and down every day.

 

[WilcoWorld]

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."

Was I your attending?

I teach my residents that your charting should match your workup.

 

[WilcoWorld]

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.

It also makes my life better. I still get to be a doctor at work.

3-5 extra minutes of listening followed by a "you know what, I can understand why you're worried, but because of XYZ I think you're going to be OK" leads to a lot of "gee, thanks doc". The other 25% get the CT/lab/whatever...

 

[emergentmd]

Was I your attending?

I teach my residents that your charting should match your workup.

Every new resident should start doing this in training. The big hurdle every resident faces is trying to figure out what an attending wants. You will never please every attending, but if your chart matches your workup/diagnosis, then life will be easier.

Your chart should reflect your workup/disposition and there should be no incongruency.

Cop #1 - I pulled over someone and they started to fight me. I am so sorry that I accidentally pulled my gun, yelled taser, and killed him, caught on bodycam. It was an obvious mistake = Jail time for manslaughter.

Cop #2 - I pulled over someone and they started to fight me. I pulled my gun, shot him, killed him, caught on bodycam. My mind said taser but I will stand by the fact that I feared for my life. It was an obvious mistake = No jury would convict after looking at the body cam. Small woman cop was fighting big guy, justified.

I choose Cop #2. Chose Cop #1 at your own peril.

 

[Siggy]

Cop #1 - I pulled over someone and they started to fight me. I am so sorry that I accidentally pulled my gun, yelled taser, and killed him, caught on bodycam. It was an obvious mistake = Jail time for manslaughter.

Cop #2 - I pulled over someone and they started to fight me. I pulled my gun, shot him, killed him, caught on bodycam. My mind said taser but I will stand by the fact that I feared for my life. It was an obvious mistake = No jury would convict after looking at the body cam. Small woman cop was fighting big guy, justified.

Of course her entire post-shooting actions cemented that it was a tragic mistake, which would have precluded using the second argument at trial.