Record Keeping

Discussion in 'Anesthesiology' started by serenity, Jul 24, 2006.

  1. serenity

    serenity Senior Member
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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
     
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  3. UTSouthwestern

    UTSouthwestern 1K Member
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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.
     
  4. jetproppilot

    jetproppilot Turboprop Driver
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    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).
     
  5. johankriek

    johankriek Membership Revoked
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    One of my attendings told me:
    "johan, we dont chart blood pressures below 100 here"
     
  6. jwk

    jwk CAA, ASA-PAC Contributor
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    What do you chart when they arrest?
     
  7. serenity

    serenity Senior Member
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    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??
     
  8. militarymd

    militarymd SDN Angel
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    I like to get my charting done before I see the patients.
     
  9. lvspro

    lvspro ASA Member
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    :laugh:
     
  10. pratik7

    pratik7 Senior Member
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    Machine error :p
     
  11. jetproppilot

    jetproppilot Turboprop Driver
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    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."
     
  12. bullard

    bullard Senior Member
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    Ha, nice. But why "yuk"?
     

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