Scribes

[RustedFox]

One other question, part of this thread was helping those Cerner folks with importing Radiology studies. Is there also a way, with smart templates, to automatically incorporate EKG's into the chart as well?

But, even if you had an image file uploaded... You'd still need to plop your interpretation in there.

I think that the EKG section of Cerner is more than adequate.

Macros, my man. Macros.

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[thegenius]

Sorry man that's what I mean, importing the EKG interpretation. Automatically importing it. Occasionally I will upload the EKG itself...take a snippet or window snapshot using the native OS tool, copy the image to the clipboard and then paste it into the chart.

Our EKG software looks like this...

Yours too?

I want the text and the intervals / segments at the top imported automagically into the chart. Right now it's a copy/paste deal and it's terrible.

 

[RustedFox]

Sorry man that's what I mean, importing the EKG interpretation. Automatically importing it. Occasionally I will upload the EKG itself...take a snippet or window snapshot using the native OS tool, copy the image to the clipboard and then paste it into the chart.

Our EKG software looks like this...

View attachment 253031

Yours too?

I want the text and the intervals / segments at the top imported automagically into the chart. Right now it's a copy/paste deal and it's terrible.

Your EKG software is light-years ahead of mine.

Its a sin that we have to ask for simple things like this, only to be told "no".
I just picked up my phone and ordered a club sandwich to be delivered to me tonight at work at 9pm.
That was easy.

 

[thegenius]

that EKG software is actually cool, you can draw lines, and segments, measure things, change the gain, draw smiley faces, and if you ask it nicely it will give you a surprise reach around.

 

[turkeyjerky]

I don't understand the desire to include the actual EKG in your note. This is already recorded in the chart in a separate location. I just don't understand the need of some people to double-document everything.

For instance, I've seen some people put in a time stamp for when a hospitalist or consultant is paged. Makes no sense to me, since our clerks put in a timed note everytime they page someone. When you get sued the whole chart will be there.

Now, I do sometimes wish it were easier to include photos of patient's rashes, etc in the chart, since it's impossible to prove after the fact what something looked like on initial presentation

 

[thegenius]

I don't understand the desire to include the actual EKG in your note. This is already recorded in the chart in a separate location. I just don't understand the need of some people to double-document everything.

For instance, I've seen some people put in a time stamp for when a hospitalist or consultant is paged. Makes no sense to me, since our clerks put in a timed note everytime they page someone. When you get sued the whole chart will be there.

Now, I do sometimes wish it were easier to include photos of patient's rashes, etc in the chart, since it's impossible to prove after the fact what something looked like on initial presentation

I do it very rarely....like a STEMI or something with a fast HR, or a questionable or cool EKG findings like a QTc > 600. It's rare like maybe 1-2/month I do it.

 

[KGflyboy]

I just dictate something like EKG showed AFIB rate 140, normal qrs interval, no ST elevations per my interpretation. That puts all the pertinent info from the EKG that I used or acted upon in my note. I think anything more is just extra time charting that won't improve my note in any way.

I do it very rarely....like a STEMI or something with a fast HR, or a questionable or cool EKG findings like a QTc > 600. It's rare like maybe 1-2/month I do it.

 

[southerndoc]

Often times pager logs aren't part of the medical record and doesn't make it to discovery. Out of all the legal work I have done (peer review, expert witness, etc.), I have never seen a pager log produced even when timely care is one of the key issues (no record of paging the cardiothoracic surgeon who defendant claims took 90 minutes to call back - oh yea, where's your proof?).

It is always good to document the time in your chart when you page and definitely when you speak to someone. Not only for legal reasons, but it's nice if you leave the department after your shift and there is a question who is admitting someone that might not have been communicated or lost during signout.

Physical picture of the EKG in your chart would only be helpful if your EKG's aren't automatically uploaded to a central server. A photo without documentation will do nothing for your MDM to support your coding. There must be an interpretation.

Never throw your consultants under the bus. Be careful with how you document because it'll come back to haunt you either with a MedExec committee, future relations, or in a lawsuit. Plaintiff attorneys love it when consultants are in a chart war. It provides ammunition to them. A simple "neurosurgery paged at 1235" and "discussed with neurosurgery (Dr. Jones) at 1250; will see in office." If you disagree with what he/she is telling you to do, be careful how you document it. Obviously document enough to support yourself legally, but resist the urge to document something "despite my pleas he refused to come see patient." Yes, I've seen that before. A more tactful way to word it would be "discussed in detail/depth regarding patient condition. Findings reviewed with the neurosurgeon on call including concerns. The neurosurgeon has recommended outpatient follow-up and does not think the patient needs emergent surgery." Always make sure you document a name and not just a specialty. The call roster might not be available when things go to trial 3 years later.

Sorry, I have strayed way off topic. I could go on and on about the bad things I've seen in charts over my years that have come back to haunt people.

 

[thegenius]

Often times pager logs aren't part of the medical record and doesn't make it to discovery. Out of all the legal work I have done (peer review, expert witness, etc.), I have never seen a pager log produced even when timely care is one of the key issues (no record of paging the cardiothoracic surgeon who defendant claims took 90 minutes to call back - oh yea, where's your proof?).

It is always good to document the time in your chart when you page and definitely when you speak to someone. Not only for legal reasons, but it's nice if you leave the department after your shift and there is a question who is admitting someone that might not have been communicated or lost during signout.

Physical picture of the EKG in your chart would only be helpful if your EKG's aren't automatically uploaded to a central server. A photo without documentation will do nothing for your MDM to support your coding. There must be an interpretation.

Never throw your consultants under the bus. Be careful with how you document because it'll come back to haunt you either with a MedExec committee, future relations, or in a lawsuit. Plaintiff attorneys love it when consultants are in a chart war. It provides ammunition to them. A simple "neurosurgery paged at 1235" and "discussed with neurosurgery (Dr. Jones) at 1250; will see in office." If you disagree with what he/she is telling you to do, be careful how you document it. Obviously document enough to support yourself legally, but resist the urge to document something "despite my pleas he refused to come see patient." Yes, I've seen that before. A more tactful way to word it would be "discussed in detail/depth regarding patient condition. Findings reviewed with the neurosurgeon on call including concerns. The neurosurgeon has recommended outpatient follow-up and does not think the patient needs emergent surgery." Always make sure you document a name and not just a specialty. The call roster might not be available when things go to trial 3 years later.

Sorry, I have strayed way off topic. I could go on and on about the bad things I've seen in charts over my years that have come back to haunt people.

Southerdoc, I always enjoy your posts like the ones above. Very informative. You should have a dedicated post about all this useful stuff.

And i'm even more interested now in the legal stuff, I just got deposed (not named) on a case I had three years ago. I guess the insurance companies are arguing over who's going to pay the ER bill, among other things. I had to respond to a line in my PE:

Neck: Supple. No C-spine tenderness. I did not range his neck due to his symptoms.

LOL