Medical Messed up patient notes + yelled at by chief resident, did I just kill my LOR?

[GoSpursGo]

Hi guys

So I messed up several patient notes on EM rotation by not including 'seen by Dr.. X' within the note, AND not getting the attending to co-sign the note. I'm unfamiliar with this EMR, and I thought the attending would at least check the note, add ammendums and their digital signature to the note prior to patient transfer or discharge. I obviously discussed these patients with the attendings, and never ordered any labs or drugs myself. While I comprehensively documented hx/PE findings, I didn't mention that it was seen with a Dr.

That being said, I thought I was doing well on this sub-I. That was until the chief resident (registrar) stumbled across a readmitted patient, looked at my note, and yelled at me in front of the whole ER (and my preceptor). He berated me for not mentioning the case was discussed or seen with an attending, and for not getting their signatures, and said that my notes look like I'm 'cruising it', and it's unprofessional for a medical student. ‘Why isn’t it co-signed?! Does that mean your patient hasn’t been seen by a DOCTOR yet?!’ My preceptor (and about 6 residents, 4 nurses... and the entire ER) watched on in the background, while I apologized, and fixed the notes. Later, my preceptor briefly mentioned my notes are reasonable, but it'd be a concern if something happened legally.

My preceptor returned my eval the other day, and scored me:

• 6/6 (truly exceptional) clinical skills
• 6/6 time management
• 5/6 (very good) team-work
• 5/6 case presentations
• 5/6 ethics
• 4/6 (good) documentation
• 4/6 safety netting.

I emailed this preceptor asking for a LOR after getting this back .

My questions are:

1. Was the fault totally on me? I thought most institutions have their attendings check the notes and sign off on it! Am I meant to see attendings sign off on notes through residency in the future?
2. There may be one or two 'lost' patients, the names/IDs of which I don't have, who are lacking a digital signature or attending representation in the note. I'm not 100% sure though. How should I remedy this situation if at all?
3. Does this LOR sound viable if he submits one? I really want this letter because he is a double-boarded US physician practicing in Australia (where I'm based) with reasonable clout.
4. I'm still a bit stressed by this situation. I have one more week at this ED. I haven't interacted with the resident who yelled at me. Do I just pretend like it didn't happen?

Sorry if this doesn't seem as 'intense' as some other consult questions, but it's a huge deal to me.

First of all, that chief was entirely unprofessional and I’m sorry that happened to you. Feedback should never be delivered in that manner.

1) The fault isn’t totally on you, as I would expect that you would get some sort of orientation on your first day explaining how things work. That said, you also should have asked about expectations on day 1, and they could have told you this. Most attendings have too many patients to manually find all their patients and need to have the note “sent” to them.
2) Not sure what if anything you can do here. You could ask the preceptors or residents if there’s any way to find your patients.
3) My honest initial reaction is you should consider this LOR gone, as I feel like the risk is likely not worth it. But I don’t know how big of a bigwig this guy would be or if anyone else has worked much with you. All you can do is sit down and ask the preceptor if you can still get a strong LOR. Hopefully he will be honest with you. And if you can get by without this letter I would strongly consider it.
4) Yep

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[AlteredScale]

1. I mean, not really. But as a 4th year medical student on a Sub-I I would have thought you had known that all notes need to be co-signed by someone by now? Why weren't you checking?
2. Agree with Spurs here, not much you can do outside of maybe letting the attending know so they can look for them (give them the date and time that you saw the patient and signed the note if you remember)
3. Not sure if an LOR from them would be great despite the evaluation. You could always ask him personally.
4. Yes, I would. That's really messed up the chief resident yelled at you in front of everyone. Very very unprofessional on their end to do so.

 

[TheBoneDoctah]

For us, we always had to "send" them to an attending or we (as a medical student) couldn't "sign" them). The way the resident went about it was incredibly unprofessional though. Personally, with the LOR, if this letter is important to you, I would talk with the preceptor directly. Just because the resident was an a** doesn't mean that the preceptor didn't enjoy having you and thought you were a good medical student. I would make sure to clarify though with him if he is willing to write you a strong letter.

 

[lord999]

2 is straightforward if you did sign your notes. Ask your Clinical Applications Coordinator to pull all notes that you signed without consigner. If you are on the Aust. Epic, use the following technical language:

"Would you please look up HNO_Note_Info for records that I am the author? I am trying to find ones where they lack a Note_Purpose = 2 (Cosign)"

4 is unprofessional and is grounds for peer review in the US, but Australian might be old-fashioned about it.

 

[TheBoneDoctah]

Ok, so he wrote me a very strong LOR.. and sent it to me via Email.

What do I do now? Upload it myself as an unwaived letter? Or ask him to create an account to do it? (he's clinically sharp, but i think this tech issue might be a struggle).

He needs to send it. It cannot come from you.

 

[GoSpursGo]

Does he have an admin who could upload it for him?

 

[lord999]

Yeah, there's too much risk if you had s public interaction. Offer to walk him through it.

 

[TheBoneDoctah]

I do advise that you really walk them through it though. The last thing you need to deal with is a “lost” letter.