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Yikes. Documentation is key here.
As an intern, I was called by a nurse for more pain meds for a patient because family felt pain was not adequately controlled. I came to assess patient, found patient sleeping. Gently shook patient to assess, patient briefly woke up but did not complain of pain, went back to sleep. Told nurse this and documented my visit and exam. Called an hour later for same. Repeat assessment, same. Documented again. Noticed that an attending from a different specialty had been by and written a note with similar assessment. Then about an hour later I was PAGED BY THE DAUGHTER to her cell phone. Turns out daughter used to work in the hospital and knew the pager system. Again declined to write for more pain meds and told her I thought directly paging me was inappropriate. Went by chart and documented this conversation.
Note that documentation was paper charts and I don’t think nurse saw me writing my notes since I sat in the dictation room.
Found out the next day that after this, the nurse paged the on call attending directly (skipping the in-house senior and the homecall chief resident in the hierarchy) to complain that said intern refused to return calls or properly assess patient who was in pain all night.
Attending point blank applauded my documentation (nurse clearly didn’t realize I’d written notes) because it basically saved my ass. At the time of the call he told the nurse that the appropriate chain of command for non-urgent issues that didn’t get a response was in-house senior and then chief and then attending. The next day he read my notes and it saved me from getting in trouble/black stain/etc.
If you didn’t write it down, it didn’t happen.
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