Progress note missing from paper chart

[ferroportin]

I'm a Medicine resident. A few days ago, I wrote a progress note, had the attending sign off on it, then put it in the chart. Today, the attending says that he can't find that note in the chart, even though he knows it was placed there (and yesterday's progress note is there as well, so the management plan can still be read). What's normally done about this? Do I have to rewrite notes in these situations? It's kind of ridiculous to have to redo work every time a clerk/staff member loses parts of a chart.

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[gutonc]

What's normally done is that hospitals enter the 21st century and use an EMR.

 

[ferroportin]

What's normally done is that hospitals enter the 21st century and use an EMR.

Well, obviously, but my hospital is stuck in the 1970s, so what can be done in the (admittedly atavistic) context?

 

[TooMuchResearch]

What's normally done is that hospitals enter the 21st century and use an EMR.

I had two signed electronic notes totally fall off charts this year. Not even a record of a deleted note.

 

[Crayola227]

Be grateful that the attending does not see this as a failure on your part, and write the darn note.

If you had written it, he hadn't seen it, and he noticed it wasn't there, even if you claimed you had written it and put it there he would always wonder if you were just saving face or spaced it.

You got lucky.

There must always be a note.
Repeat after me, there must always be a note. Every day.
Literally, there must be a note. Like medicare or someone really important won't pay if there's no progress note FOR EVERY ****ING DAY they are there.
Missing notes is an offense probably not as bad as stabbing an attending to death when it comes to keeping you around, but it's a close second. The only thing worse would be killing a patient or getting the hospital sued, and I won't comment which is worse of the two.
"You are not here to spend time with patients, you are here to get the notes done." That last quote, I am not f8cking around with you, word.

If you notice a colleague missed a note, by all means mention it or write it for them if they're not there and you can see their patient. This is not nitpicking each other but keeping each other out of hot water. If you every time you notice a missing note of someone's and you offer to write it you will make friends. Usually this will not happen or necessarily be appropriate, but understand that our least favorite task is in many ways the most important one
(don't say I'm wrong patient care is, because since we have set up the sick cycle system of documentation = hospital money = hospital = place for patients to be treated = documentation = hospital money, then yes, documentation is most important since you will sacrifice time caring for the patients, but never sacrifice a note)

You can't do those notes then fake it later, and there's only so many of those "oops here's a note after the fact" that I'm guessing you can get away with

If it happens enough just photocopy your notes and have him sign the original and copy, and keep the copy in a vault to save you work the next time it's lost (only half kidding)