can't write progress notes/consults in teaching hospital???

Discussion in 'Clinical Rotations' started by lynx, May 3, 2007.

  1. lynx

    lynx Member
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    Ok, I need your helps, guys. Have you ever experienced problems with writing progress notes or consults in the teaching hospital? Like, when the residents don't tell you/teach you what's wrong with your note but rather just rewrite it? Or tell you that there's nothing wrong with your note, yet due to hospital policies/billing purposes/attending preferences/etc you should not write a note? Or the resident just forgot to cosign or add to your note and he got busted by an attending and then they tell you not to write a note? Or they tell you to write a not but not a A/P? How are we supposed to learn then????
    I understand that in some community or non-teaching hospitals such restrictions can take place, but I'd expect from a teaching hospital be willing to TEACH us, students, including notes/consults and A/P?????
    I've had such weird experience twice during my third year in two completely different teaching hospitals....Just curious if anybody has had similar experience and did you do about it......
    THANKS:confused: :eek: :confused:
     
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  3. DrJ105

    DrJ105 Junior Member
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    Every department at my hospital has said different things about that. I generally can write a note, and either an attending or a resident will sign it if they see it.
     
  4. hale-bopp

    hale-bopp Senior Member
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    At my school, the policy varies by department at our major teaching hospital, but basically, if we are allowed to put notes in charts, someone else still has to rewrite it for billing purposes (they can only bill for social and family hx done by us or something ridiculous like that). Some departments don't let us put anything in the chart, although they are happy to go over notes that we write with us if we want (yup, it feels like a total waste of time to write notes for practice). Now I'm at an outside hospital where an attending can just cosign our note like a resident's. I wouldn't take it personally, anyway, I guess just try to find out what the hospital/department policy is early in a rotation.
     
  5. Samoa

    Physician Pharmacist 10+ Year Member

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    I wouldn't listen to anyone below the attending level about whether to write notes or not. Part of being a resident is learning to supervise medical students appropriately. Your resident got in trouble for not doing that, and should probably also be taken to task for telling you not to write notes at all as a "solution" to the problem. That's not a solution, that's an abdication of responsibility.

    You should ask the attending what to do, and follow those instructions.

    As for attendings and departments that don't want you writing notes, your Dean's office should be aware that that's happening. Being responsible for student notes is a part of the bargain when you sign up for an academic job. Yes, people have gotten sued for what students have written, but it's because they didn't perform their duty to read and correct the notes, not because the note exists in the chart.

    Again, the solution is to supervise the notes appropriately, not to deny students the learning opportunity that comes with writing a note that people are going to read and take seriously.
     
  6. Tired

    Tired Fading away
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    I'm going to go the other way, and say, just do what they tell you. If they say don't put notes in the chart, then write out your notes and ask them to review it, but don't put it in the chart. Then you look motivated, but you also don't annoy them.

    I have had two rotations where they didn't want my writing in the chart, and this strategy worked for me.
     
  7. Samoa

    Physician Pharmacist 10+ Year Member

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    It works either way. I just have a huge issue with people who accept the benefits of working in academia (residents to do your work while you live a more normal life), but don't accept the liability that comes with it (giving people opportunities to learn by doing and being held responsible).
     
  8. dpmd

    dpmd Relaxing
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    It definitely varies from institution to institution. At the county hospital where we do most of our rotations, we wrote notes that for the most part were just signed off with minimal review. The occasional resident or attending would read them thoroughly and make comments (usually on medicine doing admission H+Ps). Now, someone may have been reviewing it when I wasn't looking, but mostly I would just hand over the chart during rounds to get the appropriate signatures (resident, then attending countersignature with out without an addendum). In clinic, the attending would sign off on the note after I presented and we finalized the plan. My favorite part was in fourth year on consult services, where mine was the official consult note for the patients.

    My away rotations were both at large teaching institutions. At one, we wrote notes for the inpatients, and dictated for the clinic patients with just a countersignature done. At the other, residents were required to write their own notes even if a student put one in the chart. The team did a divide and conquer rounding technique, and I would scribe notes and let the resident sign it as their own. Since we were seeing the patients together (instead of me having to preround) I was ok with that set up. Probably was totally not allowed, but since the attendings had to write notes as well, I figured what the hell. Also, since they were signing it as their own they would actually read it and give immediate feedback if things needed to be changed, so I thought it was a better learning experience.
     
  9. Tired

    Tired Fading away
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    I agree with you, as long as that's what's actually going on. And of course I've seen that, and it's pretty sickening.

    I did have an attending who told me not to write in the chart because he had previously had a student called in for a lawsuit, and wanted to spare me the trouble of that possibly happening. Honestly, I had never thought about that before, but it would be a rude interruption to my residency to have to fly all the way back home to answer a subpoena.
     
  10. ericdamiansean

    ericdamiansean High Profiler
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    You'd be writing and filling up notes and forms for the rest of your life, so, don't be too excited about writing them now:p

    Anyway, if the policy of your hospital/department states that you can't write in them, the best you can do, if you find something very important that is not written down (which happens pretty often that medical students do a better/more complete clerking), or at that moment in time you notice something wrong with the patient, it is best to inform the attending, or what I usually do, is to write on a separate sheet of paper, and clip it to the notes (do put your name, institution, status=medical student ms3/4 etc, contact number)

    If you're allowed full clerking on the notes, then, always get a counter signature.

    The reason: Everything written on the notes is legally binding, the last thing that you want is to testify in court (makes your life during the clinical years interesting and 'dangerous' but nah, no thanks)
     
  11. Tired

    Tired Fading away
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    Even if your note is cosigned, you can still be called to testify in a malpractice suit. Occupational hazard.
     
  12. ericdamiansean

    ericdamiansean High Profiler
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    True, so if a lazy attending is asking a medical student to help clerk his/her patient, he/she should run through the notes first before signing it. I've done it countless of times, and my attending always runs through the whole history and reexamines the patient just to be doubly sure.
     
  13. Mayhem

    Mayhem Scut Bear
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    This issue does not surprise me. We have 2 different systems here. At the County hospital they treat us like doctors in training so we have to write notes and get it signed by a resident or whatever. At the University hospital we're just groupies and if you even glance at a docket someone (usually a resident) will chew you up and spit you out. To make it seem like their trying to help us learn, the university doctors want us to keep our own notes and turn them in at the end of the rotation. Of course, it's so pointless because every doctor has a different quota (1 or 2 or 8 or 20) and few bother to actually read them at the end of the rotation, provided you even get them back.
     
  14. ericdamiansean

    ericdamiansean High Profiler
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    I've come across that too. I had more freedom writing notes in a semi-government hospital (also a teaching hospital) in comparison to a full-government (also a teaching hospital), the only department which never allows students to write would be Obgyn.
    Currently, we are told to include our notes in the patient's folder, probably just to see if we're clerking our patients. I don't like it because my personal notes are always in a mess:laugh:
     
  15. lynx

    lynx Member
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    Thanks guys for the input! I felt frustrated and now I realize that it's way more common than I thought it was...:thumbup:
     
  16. Bubb Rubb

    Bubb Rubb Woo woo!
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    here's how my required rotations have treated me with regard to notes:

    ob/gyn: ok, no freedom here. didn't do squat except watch a bunch of c-sections and turn in 6 writeups over 6 weeks that were duly ignored

    family med: wrote the official EMR note on all the patients that i saw first, so typically ~8/day. was a wonderful experience, especially so early in the year

    peds: wrote paper notes on inpatients in the chart, co-signed by an attending. outpatient: no note-writing, except a cursory note-per-day handed in to the site director, again duly ignored

    surgery: would write paper notes on inpatients in the chart, co-signed by the team. in clinic would write a skeleton note that would then be dictated by the attending.

    psych: VA site, full CPRS access. would write all notes, co-signed by attending. the consult note would be mine, although with no A/P (even though what i suggested would often be the recommendation). inpatient notes would have my own A/P.

    internal med: would write full admit notes, co-signed by intern. the intern would have to write her/his own admit note, however. subsequent daily notes went in the EMR with the intern co-signing (but with no daily intern/R3 note). the attendings would always write their own short paper notes in the chart as well. on outpatient my dictation goes in the paper/electronic chart as the official note.

    so i guess it has been a mixed bag, looking back. i prefer to remember the positive experiences, namely family med, psych, and internal med. :D
     

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