"If you didn't document it, you didn't do it"

[DrDude]

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Anyone else disappointed/saddened by the state of relationships between people in this profession? What could be almost described as paranoia and mistrust all around. Seems what is so often touted as a healthcare "team" is more like a collection of individuals looking out to cover their own a$$es. On almost a daily basis I hear at least one reference to "not trust anyone". Nice teamwork.

Which brings me to the title of this thread. So if you do something but don't write it down then you didn't do it. Wow.

 

[HarryRosenMD]

Hi...

In terms of the peer relations... you pretty much nailed it. Its not everyone, however.
In terms of the documentation... just write your notes as though someone is going to cover for you the following day. Just convey what is needed to potentially pass the torch - and you'll be fine.

 

[Blade28]

That's a function of how litiginous our society has become.

What I was taught during orientation:

(1) Trust no one
(2) Document everything
(3) Assume nothing

 

[Hurricane95]

Yep...that's how it is.
Write and document EVERYTHING.
Otherwise that one patient you suggested to get further studies after a fishy mammogram will come back two years down the road suing you because she never knew there was a chance she has breast cancer. Even though you told her. Twice.

 

[nonesuchgirl]

+1 to Blade and HR, MD.

That, and if you write it all down, you don't have to remember it. 🙂

 

[smq123]

Anyone else disappointed/saddened by the state of relationships between people in this profession? What could be almost described as paranoia and mistrust all around. Seems what is so often touted as a healthcare "team" is more like a collection of individuals looking out to cover their own a$$es. On almost a daily basis I hear at least one reference to "not trust anyone". Nice teamwork.

Hmm...I see your point, but I don't think that it's necessarily such a terrible thing.

By not trusting what someone else (a nurse, an ER attending, another med student) has told you, it's possible that you might discover a mistake that could have really harmed a patient.

(I'm sure you've seen it on your rotations - the nurse tells you that the patient had a "quiet night," but his tele alarms tell a very different story, the ER tells you that the patient is "totally stable"...but when you see him, his sats are down in the low 70s.)

So yes - constantly double checking everything is a pain and can create an atmosphere of paranoia, but I think it's preferable to being too laid back about things.

As for documenting everything, it isn't just to "cover your a**" - it also helps night float if that patient has an issue in the middle of the night. And all that documentation also comes in handy when you have to write the off-service notes before your rotation ends.

 

[Amy B]

My attorney asked the nurse that killed my son during depositions as to why she didnt have ANYTHING documented from the time she took out the central line IMPROPERLY as she discharged him until 7 hours after he was taken to ICU as he was dying from her stupidity..... her answer to my lawyer was... "I didnt document anything becuase I wanted to see how things would work out and get the final result of that day."😕

 

[nonesuchgirl]

My attorney asked the nurse that killed my son during depositions as to why she didnt have ANYTHING documented from the time she took out the central line IMPROPERLY as she discharged him until 7 hours after he was taken to ICU as he was dying from her stupidity..... her answer to my lawyer was... "I didnt document anything becuase I wanted to see how things would work out and get the final result of that day."😕

That nurse will eventually get what is coming to her. I am so sorry for your loss.

 

[OncoCaP]

When it comes to "if you didn't document it, ..." look at the positive corollary. If you write something down, people will generally trust that you did it ... unless you record normal vital signs for a deceased patient, PERLA for the patient with a glass eye, normal reflexes on an amputee, etc.

 

[Gut Shot]

So if you do something but don't write it down then you didn't do it. Wow.

In my hours spent pouring over the charts of people I'm about to autopsy, I'd much rather have overdocumentation than the opposite. Like it or not, the chart is how we communicate, and if we can't take the time to record what is done, we're doing an enormous disservice to the patient and our colleagues.

Poor documentation is a MAJOR source of medical errors, be it for something as stupid as illegible handwriting on the order forms. If we could ever move to transferrable electronic charts perhaps our collective paranoia would be less justified.

 

[nonesuchgirl]

In my hours spent pouring over the charts of people I'm about to autopsy, I'd much rather have overdocumentation than the opposite. Like it or not, the chart is how we communicate, and if we can't take the time to record what is done, we're doing an enormous disservice to the patient and our colleagues.

Poor documentation is a MAJOR source of medical errors, be it for something as stupid as illegible handwriting on the order forms. If we could ever move to transferrable electronic charts perhaps our collective paranoia would be less justified.

I think it's coming but it's

1. expensive
2. time consuming to transition to
3. requires a metric f*ck ton of computers

Where I work (there needs to be an abbreviation for that), they are trying to move away from paper charts... the problem being that there are

1. too many patients
2. too few computers

And this is a major place, I can't imagine how the little guys ensure continuity.

 

[Tired]

That's a function of how litiginous our society has become.

I'm not nearly as pessimistic about this aspect of medicine as you are.

It's not about getting sued, it's about getting paid.

When you take you car to the mechanic, how would feel about not getting an itemized list of what was done, what parts were replaced, and how long it took? Would you pay for your car repair if the mechanic told you, "Oh, some things weren't working right so we fixed it. That'll be a $1200."

And how many times do we go back through a patient's last admission, and try to discern what studies were done, what treatments were performed, and feel totally lost because the tool before you didn't bother to put any of it in the discharge summary? How many studies and labs do we end up repeating because no one wrote down the previous result?

Documentation is basic and absolutely necessary. It's not "if you didn't document it, you didn't do it", it's "if you didn't document it, you're a f-ing ***** and I want to punch you in the head."

 

[arsenewenger]

That's a function of how litiginous our society has become.

What I was taught during orientation:

(1) Trust no one
(2) Document everything
(3) Assume nothing

The reason I like Third-World countries.

 

[Its_MurDAH]

The reason I like Third-World countries.

indeed

 

[DocPsychosis]

Oh please 🙄. Stop complaining about litigation. It's not (all) about covering your ***, it's about caring for the patient. If you do a procedure or exam, write it down so no one else doubles up. If you don't write it down, someone else knows it still needs doing. That way everything gets done right, simple as that.

e: see Gun Shot, whose post I missed somehow.

 

[ZagDoc]

I think it's coming but it's

1. expensive
2. time consuming to transition to
3. requires a metric f*ck ton of computers

Where I work (there needs to be an abbreviation for that), they are trying to move away from paper charts... the problem being that there are

1. too many patients
2. too few computers

And this is a major place, I can't imagine how the little guys ensure continuity.

Electronic isn't the magic bullet either. My university has completely transitioned to electronic records/charting and most medical professionals spend just as much time every dealing with quirks in the software, mucking through menus, and dealing with electronic orders/scheduling snafus as they did in the paper days. And these are younger clinicians I would consider pretty computer savvy.

The software is very cumbersome, mainly due to the diversity of medicine as a practice. What an oncologist needs from charting is very different from an interventional cardiologist, nephrologist, general surgeon, etc. The software tries to do it all, and ends up not doing anything particularly well. Sure makes billing easier though! You'll never leave out a full ROS again!

 

[DrDude]

Oh please 🙄. Stop complaining about litigation. It's not (all) about covering your ***, it's about caring for the patient.

It's easy to downplay how much the fear of litigation dictates the amount of documentation. A lot of it doesn't do anything for patient care but rather done to CYA just in case. If an overly anxious nurse calls you in the middle of the night and you go see the patient and he's doing fine you're supposed to document he's fine. Why? Not because documenting he's fine improves patient care, but because if anything should go wrong afterwards and you didn't document you went and saw the patient and he was a-OK, people will get all self-rightous and accuse you of not seeing the patient because you didn't write it in the chart. That's the kind of stuff I'm talking about, not stuff like documenting procedures and meds. In other words, a doctor's word means nothing anymore unless it is written down.

 

[Blade28]

The reason I like Third-World countries.

I think the PC term is "developing country." 😉

I'm not nearly as pessimistic about this aspect of medicine as you are.

Documentation is basic and absolutely necessary. It's not "if you didn't document it, you didn't do it", it's "if you didn't document it, you're a f-ing ***** and I want to punch you in the head."

(1) I'm just jaded at times, perhaps.

(2) Now THIS I agree with! 👍

Oh please 🙄. Stop complaining about litigation. It's not (all) about covering your ***, it's about caring for the patient. If you do a procedure or exam, write it down so no one else doubles up. If you don't write it down, someone else knows it still needs doing. That way everything gets done right, simple as that.

It's not always quite that simple.

DrDude makes an excellent point above. In addition, here, we have to write a note in the chart documenting when we obtain informed consent from the patient (for procedures/blood transfusions) - this is IN ADDITION to the informed consent form itself.

Why? Why wouldn't the form itself be sufficient? It's because we've run into problems in the past when the patient later claimed that they weren't properly consented, or didn't remember signing the form, etc. (despite their signatures being on said form).

So now I document that I talked to the patient and whoever else was present at the bedside - spouse, parents, siblings, children, etc.

 

[Gut Shot]

Electronic isn't the magic bullet either. My university has completely transitioned to electronic records/charting and most medical professionals spend just as much time every dealing with quirks in the software, mucking through menus, and dealing with electronic orders/scheduling snafus as they did in the paper days.

There is good software for this purpose and not so good. My med school went with something that was not only awful but very expensive. The would have been better adopting the same system as the VA: not flashy, but simple, intuitive and reliable. And open source code (=cheap).

 

[kingcer0x]

Is it me, or does nursing documentation really just exist for the purpose of writing things like "MD aware" or "notified MD" or "orders received". In turn, the purpose of such wording seems more oriented towards avoiding future litigation rather than communicating...? I wonder if anyone ever tried "nurse aware, responded with snicker"