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Record Keeping

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serenity

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I am in a dilemma
Being a new CA-1, I was very diligently taking the BP readings off the monitor,the patient had an arterial line and the BP was varying 10 to 30 points beat to beat.When my attending saw my charting he told me to look at the bigger picture and chart accordingly,which seemed to make sense
But,my question is that if this patient's records were interrogated,wouldn't the chart look forged .
What is the usual practice,please shine some light on this issue
 

UTSouthwestern

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Any chart can be made to look forged even if you diligently record vital signs. While you want to be as accurate as possible, you also don't want to be so accurate as to include times when a false reading is being given (pulse ox fell off the patient, art line damped by surgeon leaning heavily on the arm, etc.) or when a normal variation is occurring (you put the patient in steep reverse trendelenburg for part of the gastric bypass procedure, bp drops, but corrects itself a couple of minutes later). Stay with the general trend of the vital signs because if you are so focused on charting vital signs exactly at the 5 minute mark, you are likely not paying close enough attention to your patient.
 

jetproppilot

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UTSouthwestern said:
Any chart can be made to look forged even if you diligently record vital signs. While you want to be as accurate as possible, you also don't want to be so accurate as to include times when a false reading is being given (pulse ox fell off the patient, art line damped by surgeon leaning heavily on the arm, etc.) or when a normal variation is occurring (you put the patient in steep reverse trendelenburg for part of the gastric bypass procedure, bp drops, but corrects itself a couple of minutes later). Stay with the general trend of the vital signs because if you are so focused on charting vital signs exactly at the 5 minute mark, you are likely not paying close enough attention to your patient.

One of my attendings told me once, after charting the difficult time I had putting in a spinal....CA-2 mind you....

"Jet, WHAT ARE YOU, A SCHMUCK??? THE CHART IS NOT A CONFESSIONAL!"

Exact words (except the Jet part).
 

johankriek

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One of my attendings told me:
"johan, we dont chart blood pressures below 100 here"
 

jwk

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johankriek said:
One of my attendings told me:
"johan, we dont chart blood pressures below 100 here"
What do you chart when they arrest?
 

serenity

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UTSouthwestern said:
Any chart can be made to look forged even if you diligently record vital signs. While you want to be as accurate as possible, you also don't want to be so accurate as to include times when a false reading is being given (pulse ox fell off the patient, art line damped by surgeon leaning heavily on the arm, etc.) or when a normal variation is occurring (you put the patient in steep reverse trendelenburg for part of the gastric bypass procedure, bp drops, but corrects itself a couple of minutes later). Stay with the general trend of the vital signs because if you are so focused on charting vital signs exactly at the 5 minute mark, you are likely not paying close enough attention to your patient.
Got your point there,I was worried about the medico legal issues,if God forbid a chart is interrogated,but I think your advice makes a lot of sense.
Also,does the monitor display have a memory to store previous patient's data??
 

militarymd

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I like to get my charting done before I see the patients.
 

jetproppilot

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militarymd said:
I like to get my charting done before I see the patients.

I worked for a few months closely with a pedi-cardiothoracic (yuk, by the way) anesthesiologist during residency.

At the end of one of the first cases I did in tandem with her, I asked:

"Dr #^#&&, what do I put for total volume administered?"

She answered

"you put whatever it's supposed to be."
 
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