Funny things you've seen on charts...

[kdburton]

I saw a thread about this a while back and thought it was hilarious. I figured I'd start up a new one since many students are on some sort of break right now and may have time to contribute.

I was in the ED a couple weeks ago and one patient's chart read that they were allergic to, no joke, elephants. I couldn't stop laughing

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[Law2Doc]

I saw a thread about this a while back and thought it was hilarious. I figured I'd start up a new one since many students are on some sort of break right now and may have time to contribute.

I've seen several nursing notes where they indicated that a "type and scream" was performed on a patient.

 

[rachmoninov3]

CC: "went to get a beer and feel over a wall"
--H&P

IM steroids are sometimes necessary in "noncompliant, fatality-prone, mentally delayed individuals" ---notes from first year

 

[angry energy]

"patient is BBB"

(when i asked the nurse, it meant Big, Black, and Boisterous)

 

[mjl1717]

I always thought "No borborygami" was at least a little humorous.

 

[Law2Doc]

"patient is BBB"

(when i asked the nurse, it meant Big, Black, and Boisterous)

I've also seen "patient is FLK" (funny looking kid -- meaning there is likely something genetic/congenital going on). It's actually considered bad form to put this kind of acronym in a chart BTW.

 

[angry energy]

I've also seen "patient is FLK" (funny looking kid -- meaning there is likely something genetic/congenital going on). It's actually considered bad form to put this kind of acronym in a chart BTW.

i've seen that too...

most institutions, if not all, have a policy that med student notes are not included in the official chart (tho u can often find them in medical records, and are presented with the case during M&M conferences). but when that patient sues, med student notes are not included when handed over to attorneys.

when screening, many other implicating notes (ie the ones that say FLK) are usually destroyed too; i've seen it happen.

when you realize this, and grow the balls to push the envelope and test things, you can try putting some insane stuff in there.

the most i've done was at 3am on ob, when a patient came in with a pus-filled abscess in her vagina...my note said "***** is *****" (***** is pus-sy).

attending got a kick out of it, and blamed it on lack of sleep. now that fourth year is here, once match day arrives, i'll see how ridiculous i can get

 

[Law2Doc]

when screening, many other implicating notes (ie the ones that say FLK) are usually destroyed too; i've seen it happen.

If you saw the destruction of medical files, then you witnessed a crime. These notes need to be kept intact and have to be turned over when subpoenaed. The FLK note I saw I actually saw in the context of my prior career -- it absolutely had to be turned over to a court. So no, I wouldn't push the envelope once you are an MD because if your hospital follows the laws governing record keeping, something like that absolutely will find its way into the hands of an annoyed plaintiff. These kinds of things are only funny when you don't have to defend against them. The jury is already suspicious of doctors as is; something like this can make you seem callous and sink whatever chances you might have of prevailing. The smart course of action is to always write your notes with the thought that some day it might get read into the record in a legal proceeding. Because it just might.

 

[bcat85]

If you saw the destruction of medical files, then you witnessed a crime. These notes need to be kept intact and have to be turned over when subpoenaed. The FLK note I saw I actually saw in the context of my prior career -- it absolutely had to be turned over to a court. So no, I wouldn't push the envelope once you are an MD because if your hospital follows the laws governing record keeping, something like that absolutely will find its way into the hands of an annoyed plaintiff. These kinds of things are only funny when you don't have to defend against them. The jury is already suspicious of doctors as is; something like this can make you seem callous and sink whatever chances you might have of prevailing. The smart course of action is to always write your notes with the thought that some day it might get read into the record in a legal proceeding. Because it just might.

L2D, You put away that J.D. and join the team!

 

[Law2Doc]

L2D, You put away that J.D. and join the team!

Oh I use my black magic for good now, instead of evil.

 

[45408]

The smart course of action is to always write your notes with the thought that some day it might get read into the record in a legal proceeding. Because it just might.

I'm less concerned now, because I'm not operating under any sort of license of my own, but man, when I worked as an EMT, I wrote every report with the thought of "how would this look in court?" I'm too paranoid.

 

[bcat85]

Oh I use my black magic for good now, instead of evil.

Good work.

 

[Law2Doc]

I'm less concerned now, because I'm not operating under any sort of license of my own, but man, when I worked as an EMT, I wrote every report with the thought of "how would this look in court?" I'm too paranoid.

This kind of paranoid person tends to have a longer career.

 

[Depakote]

I'm less concerned now, because I'm not operating under any sort of license of my own, but man, when I worked as an EMT, I wrote every report with the thought of "how would this look in court?" I'm too paranoid.

Our medical documentation lecture was given by a JD. He told us "Don't write your notes in a way that if a plaintiff's attorney were to blow-it up on a giant projector screen in front of a jury, you'd want to hide your face... 'cause that's exactly what they'll do".

the most i've done was at 3am on ob, when a patient came in with a pus-filled abscess in her vagina...my note said "***** is *****" (***** is pus-sy).

 

[PeepshowJohnny]

Yeah, I'm a total wuss about writing my notes. I think I honed the skill on my Trauma rotation because I had to document numerous times when patients were noncompliant and beligerent in the most sterile, analytical manner ever.

Instead of writing "Patient is being a huge douche and refusing to even acknowledge me when I walked in the room and then swore at me and told me to leave." I'd write

"Walked in to room patient found sitting in bed, watching TV. Patient did not respond to greeting and remained facing TV with an obvious angered expression. Patient is in no distress and further attempts to engage or examine the patient led to him telling me to "Get the *expletive* out man". Later discussion with the RN revealed the patient refused morning blood draws after the nurse would not give him his dose of pain medication (which was not scheduled for another two hours)."

 

[Agent Splat]

ED nurse's note at the VA hospital...

"patient states I am the 'meanest son of a b***h he has ever seen'."

also, on patient orders: "give 2 shots brandy BID"

 

[45408]

This kind of paranoid person tends to have a longer career.

Better than writing "pt is very sexy" yes, but I don't want it to be an overbearing burden on my mind at all times. It's nice to know that I have a few years to practice writing my notes and such.



Just curious - I've often heard the quote "If you didn't document it, it didn't happen." What if the patient tells you something, and you don't document it, and it later turns out to be important? E.g., the patient tells you they're on a drug - and there's no physical proof to show that they told you - and they have a debilitating interaction from another drug, do they have a case?

 

[TarHeelEMT]

I always love the nursing home charts that indicate that a patient is both allergic to and on a daily dose of a particular medicine.

 

[DickyV]

Just curious - I've often heard the quote "If you didn't document it, it didn't happen." What if the patient tells you something, and you don't document it, and it later turns out to be important? E.g., the patient tells you they're on a drug - and there's no physical proof to show that they told you - and they have a debilitating interaction from another drug, do they have a case?

Yes!

 

[Ashers]

ED nurse's note at the VA hospital...

"patient states I am the 'meanest son of a b***h he has ever seen'."

also, on patient orders: "give 2 shots brandy BID"

If it's a nursing note and at the VA, it's sure to say "Client" because nurses are now supposed to call patients clients and have their own "nursing diagnoses" (which are not medical somehow).

 

[45408]

Yes!

Isn't it his word versus yours? That's not usually considered evidence unless it's coming from a police officer or similar.

 

[Law2Doc]

Isn't it his word versus yours? That's not usually considered evidence unless it's coming from a police officer or similar.

It's considered evidence no matter who it comes from. It might not be persuasive, because of your vested interest, but it is certainly evidence.

 

[45408]

It's considered evidence no matter who it comes from. It might not be persuasive, because of your vested interest, but it is certainly evidence.

Well sure, but then there's the diametrically opposed evidence coming from me, and if there's no further witnesses or documentation, isn't that about the end of that? If Bob says I punched him two years ago, and I say that I didn't, and there's no evidence or witness to corroborate either of our stories, isn't the case dead in the water?

 

[Law2Doc]

Well sure, but then there's the diametrically opposed evidence coming from me, and if there's no further witnesses or documentation, isn't that about the end of that? If Bob says I punched him two years ago, and I say that I didn't, and there's no evidence or witness to corroborate either of our stories, isn't the case dead in the water?

It can be. Depends on whether he can make out a prima facie case to survive dismissal. So even though you disagree that you hit him, and no one else witnessed the event, if he can come up with someone who later saw his black eye, or a doctor bill, or a photograph, or the cab receipt from the ride home he got because he was too distraught to drive, or the diary entry he made on that date, he may have a case. Even a corroborating witness may not mean that party prevails -- if the corroborating witness was paid or coerced or Bob's estranged wife, then he may still have a shot. A jury will decide who is telling the truth -- that's what they are there for. Most suits actually are battles of my word versus yours, at least in part. Doesn't mean someone can't prevail or that neither word is going to be deemed valid. It also doesn't mean a court won't put huge weight on what is contained in the charts over what didn't make it in there. There are certainly things you have to prove in a case; damages for example. But if someone swears they told you something in an affidavit, that generally gets them their day in court. They'll need to show more to win, but might get a foot in the door. And when you testify that everything they told me I put in the chart and show them evidence that you dutifully logged other conversations on other dates, that tends to strengthen your case, but often doesn't mean they don't get to put on their own case. It's all about gamesmanship. You need a certain amount of evidence to survive dismissal, and then a higher standard to actually win. But once you file a suit, and survive dismissal, you get discovery and can sometimes obtain the critical facts you are missing. And if you did, in fact, hit Bob, it usually pays to settle early, to avoid the nuisance of a trial, even if you think you can win on the battle of claims.

 

[DickyV]

Isn't it his word versus yours? That's not usually considered evidence unless it's coming from a police officer or similar.

I think the lawyer answered this rather completely. Testimony can certainly be weighted differently by a jury (or a judge, if considering dismissing a case), but "his word" will be heard.

Law2Doc, I don't have any figures, but wouldn't the vast majority of witnesses (in criminal and civil cases) be civilians, not police officers?

 

[indo]

"26 yo g7p6"

 

[45408]

"26 yo g7p6"

nice post count