What do you guys do

[pgg]

When you take over a case and find that the charted vital signs are a long string of bull****?

Honestly, this happens to me in some non-trivial fashion at least once a month. I go in to relieve someone, look back through the monitor history, and while the monitor has a 15 or 20 minute series of post-induction vital signs like 70/30 and 68/35 and 80/40 and 72/33 ... the chart has a nice smooth stretch of 100/50. Frequently the only part of the goddamn thing that's readily legible.

Nobody's ever got a HR of 125 on paper either.

I'm not talking about "smoothing" a couple of abberrant values, or correcting for a surgeon leaning on a cuff periodically, I mean unashamed pure unadulterated bull****.


Reason #62 why I like the places with EMRs ... they keep people honest.

I bet a study could be done to show a positive correlation between ephedrine/phenylephrine consumption and hospitals with anesthesia EMRs.

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[pie944]

When you take over a case and find that the charted vital signs are a long string of bull****?

Honestly, this happens to me in some non-trivial fashion at least once a month. I go in to relieve someone, look back through the monitor history, and while the monitor has a 15 or 20 minute series of post-induction vital signs like 70/30 and 68/35 and 80/40 and 72/33 ... the chart has a nice smooth stretch of 100/50. Frequently the only part of the goddamn thing that's readily legible.

Nobody's ever got a HR of 125 on paper either.

I'm not talking about "smoothing" a couple of abberrant values, or correcting for a surgeon leaning on a cuff periodically, I mean unashamed pure unadulterated bull****.


Reason #62 why I like the places with EMRs ... they keep people honest.

I bet a study could be done to show a positive correlation between ephedrine/phenylephrine consumption and hospitals with anesthesia EMRs.

With some EMRs a right click and edit value can create that same string.

Are the people attempting to correct the BPs? Or do they just change the value for charting and accept the actual value?

 

[pgg]

With some EMRs a right click and edit value can create that same string.

Are the people attempting to correct the BPs? Or do they just change the value for charting and accept the actual value?

I think they care enough about the 70/40s to not want to document them, but not enough to actually do something about them. It's bewildering.

 

[deleted126335]

With some EMRs a right click and edit value can create that same string.

Are the people attempting to correct the BPs? Or do they just change the value for charting and accept the actual value?

Actually I think that in most EMR that the raw data is preserved. It can and is subpoenaed so every edit and retype is findable.

 

[BLADEMDA]

Actually I think that in most EMR that the raw data is preserved. It can and is subpoenaed so every edit and retype is findable.

You are correct

 

[Frank Rizzo]

Actually I think that in most EMR that the raw data is preserved. It can and is subpoenaed so every edit and retype is findable.

100% correct!

 

[Ignatius J]

We are paper charting. A lot of people think "Oh, he won't be involved in his case if he doesn't chart EVERYTHING on a paper chart". I heartily disagree and think that's a crock. The bigger and more involved the case, the bigger the chart looms in the back of your head as you go an hour or two hours or, god forbid, the whole case without getting to chart anything. Then, you drop the patient off in SICU and try and chart a rollback craniotomy from memory. Let's enter the 21th century. We don't need to be sitting down pencilling in every statistic on our patient every 5 minutes. We can rely on technology to have our back a little bit these days and be just as involved with the case. It's a waste of time and takes away from taking care of the pt. Especially in big cases.

Just my .02.

 

[Robert Loblaw]

i am joining a group that paper charts and the nightmare scenario you describe is quite intimidating. having had emr the entirety of my training i am dreading my first ****storm trauma...the paper is so impractical.

 

[Laryngophed]

When you take over a case and find that the charted vital signs are a long string of bull****?

Honestly, this happens to me in some non-trivial fashion at least once a month. I go in to relieve someone, look back through the monitor history, and while the monitor has a 15 or 20 minute series of post-induction vital signs like 70/30 and 68/35 and 80/40 and 72/33 ... the chart has a nice smooth stretch of 100/50. Frequently the only part of the goddamn thing that's readily legible.

Nobody's ever got a HR of 125 on paper either.

I'm not talking about "smoothing" a couple of abberrant values, or correcting for a surgeon leaning on a cuff periodically, I mean unashamed pure unadulterated bull****.


Reason #62 why I like the places with EMRs ... they keep people honest.

I bet a study could be done to show a positive correlation between ephedrine/phenylephrine consumption and hospitals with anesthesia EMRs.

Forgive my ignorance, but is it really that much more work to record the accurate vitals, then give and record giving the appropriate agent? Am I missing something here?

 

[B-Bone]

Forgive my ignorance, but is it really that much more work to record the accurate vitals, then give and record giving the appropriate agent? Am I missing something here?

when the sh&* is hitting the fan, you don't have time to go near the chart. I recall a few cases where I had 4-5 anesthesiologists in the room all working together and still no one having time to chart.

Example from my last month of residency:
Little old lady 1 month s/p AVR for "sternal wound debridement". sternum is mush. surgeon accidentally "debrides" the anterior wall off the RV. Over 10 minutes, gave 30 units blood products, 10 mg epi, 8 mg atropine, 40 units vasopressin, 8 g calcium, placed second cordis. extra CV surgeon comes in to place femoral bypass cannulas while primary surgeon tries to fix the hole. Just checking 30 units of products takes 10 minutes and 2 people. Hell, setting up the fricking belmont can take 10 minutes. This happened in a giant tertiary center at 2 pm with tons and tons of resources/extra people. And there was still no charting. If this happened at my PP gig, the pt would have almost certainly died, and I can guarantee there would be no charting.

So long story short: yes, you are missing something.

 

[Laryngophed]

when the sh&* is hitting the fan, you don't have time to go near the chart. I recall a few cases where I had 4-5 anesthesiologists in the room all working together and still no one having time to chart.

Example from my last month of residency:
Little old lady 1 month s/p AVR for "sternal wound debridement". sternum is mush. surgeon accidentally "debrides" the anterior wall off the RV. Over 10 minutes, gave 30 units blood products, 10 mg epi, 8 mg atropine, 40 units vasopressin, 8 g calcium, placed second cordis. extra CV surgeon comes in to place femoral bypass cannulas while primary surgeon tries to fix the hole. Just checking 30 units of products takes 10 minutes and 2 people. Hell, setting up the fricking belmont can take 10 minutes. This happened in a giant tertiary center at 2 pm with tons and tons of resources/extra people. And there was still no charting. If this happened at my PP gig, the pt would have almost certainly died, and I can guarantee there would be no charting.

So long story short: yes, you are missing something.

Just reading your scenario above puckered me up. I have no doubt that sometimes the crap hits the fan and charting goes to crap, but that wasn't the scenario painted by pgg, as I read it. I realize that there are certainly times where charting would be a detriment to the patient, like your scenario above. I could have certainly read too far into it or phrased my question poorly, but I was interested in what sounds like the non-emergent cases that (I think) pgg was describing above.

 

[pgg]

when the sh&* is hitting the fan, you don't have time to go near the chart. I recall a few cases where I had 4-5 anesthesiologists in the room all working together and still no one having time to chart.

The cases I'm describing are not chaotic no-time-to-chart. We've all done cases where an hour+ in is the first time you have time to chart, and you joke about makin' up a pack o' lies to fill in the gaps. Even then though, most of the time the monitor history is there so that the chart accurately reflects reality, +/- a couple of reasonable and honest guesses to fill in the gaps.

But the ones that annoy me are the lap choles or similar routine cases, usually though not always in a young healthy patient, where vital signs I wouldn't ignore are being ignored, while the chart is (to be blunt) falsified. I don't know how else to put it.

Even if it's a healthy young patient that isn't going to be hurt by 15 or 20 min of moderate hypotension, it just rubs me the wrong way to see them adding 30 to the numbers on the monitor. Maybe I'm just an OCD pedant. But it annoys me.

Forgive my ignorance, but is it really that much more work to record the accurate vitals, then give and record giving the appropriate agent? Am I missing something here?

I think you're missing the same thing I am. If these guys are dissatisfied enough with the BP to write something else in the chart, why aren't they fixing it?

 

[Jay K]

Good god, pgg, we could be twins... Yes, annoys me to no end.

 

[loveoforganic]

Seems like a ridiculously unethical way to CYA ::

 

[Bertelman]

So long story short: yes, you are missing something.

Pretty sure he was referring to the OP, not the discussion of paper v. electronic.

And I happen to currently be at a gig with a loathsome electronic record. Takes me longer to chart the electronic record than a paper chart in residency. In a heart room. And I was more likely to find relevant, useful prior anesthetic records that are easy to interpret at my old paper gig than I am now. I would venture to guess a printed record of a 2 hr lap chole here would be 5 pages of worthless ink.

I thought when I started residency that I would hate the paper chart, but thus far I have not found an electronic OR record to be some magical panacea for a better day, nor is it significantly better for patient care in my mind.

Just my experience.

 

[sevoflurane]

When you take over a case and find that the charted vital signs are a long string of bull****?

Honestly, this happens to me in some non-trivial fashion at least once a month. I go in to relieve someone, look back through the monitor history, and while the monitor has a 15 or 20 minute series of post-induction vital signs like 70/30 and 68/35 and 80/40 and 72/33 ... the chart has a nice smooth stretch of 100/50. Frequently the only part of the goddamn thing that's readily legible.

Nobody's ever got a HR of 125 on paper either.

I'm not talking about "smoothing" a couple of abberrant values, or correcting for a surgeon leaning on a cuff periodically, I mean unashamed pure unadulterated bull****.


Reason #62 why I like the places with EMRs ... they keep people honest.

I bet a study could be done to show a positive correlation between ephedrine/phenylephrine consumption and hospitals with anesthesia EMRs.

If patients are consistently being mismanaged, then I would do one of 2 things:

1) I wouldn't take over a case.
2) I would gently and kindly have a conversation about my concerns.

A totally healthy patient with BP's in the mid 60's-80's will, at the very least, have a higher likelihood of PONV. Plenty of studies supporting this.

At the other extreme, if a patient has critical AS or MS or something of that flavor... you are running a slippery slope. This is ABSOLUTELY unacceptable and in extremely poor form. Reminds me of a case during residency where a junior (and attending) resident did not appreciate the severity of AS. Big induction dose, hypotension that wasn't immediately corrected- fiddled around post-induction trying to get an a-line. The patient coded and died. Terrible.

We are the patients guardians in the OR. If you forget that, you need to find another job.

 

[Mman]

We are 100% EMR so it's not an issue.

If it was an issue, I'd start calling out people when I went in their room and suggest that I might not be relieving them if their charting does not reflect reality.

 

[OB1🤙]

I just start charting real vitals and my interventions at the point at which I took over. Makes it fairly obvious what was going on before.

You ask how is it conceivable that this happens? I say it's because there are lots and lots of shitty anesthesiologists out there. Which is a sad truth, but a truth nonetheless.

 

[IlDestriero]

I just start charting real vitals and my interventions at the point at which I took over. Makes it fairly obvious what was going on before.

You ask how is it conceivable that this happens? I say it's because there are lots and lots of shitty anesthesiologists out there. Which is a sad truth, but a truth nonetheless.

Amen. Calling them out on it afterward in private. I wouldn't want to take over a case full of fantasy vitals, he strokes out after induction and now it's your bad outcome and lawsuit. I used to see this with some of our "friends" in the Navy. Pointed it out to the chair and residency director. No response. Same dramatically deficient, malpractice level cover up of the real, frightening, vital signs.
Maybe print the grid from the monitor, copy the paper record and give it to risk management. Hahaha.
Cheers!

 

[pgg]

I just start charting real vitals and my interventions at the point at which I took over. Makes it fairly obvious what was going on before.

That's what I've usually done. Part of wants to call them on it and just let the drama unfold, mostly I just want to get on with my life. I can't make a stink every time I see someone do something stupid.

Maybe print the grid from the monitor, copy the paper record and give it to risk management. Hahaha.

Heh, that's surely the nuclear option ...

 

[cincincyreds]

What I do is try to be in rooms that go all that day, that way I don't relieve anyone. I do all my own cases and will stay until finished. If it is going to be extra 30 minutes, I rather stay than having to find out there was an issue in the morning.

I've had both the computer and the paper record. I prefer the paper. With the computer, I feel like if I don't explain each abnormal value, I would be setting myself up for litigation. With the paper, I am specifically writing each vital, and I can show I am temporizing a sysolic BP of 80 with phyenylephrine and turning my agent % down. I feel this is quicker than typing a separate note in a computer record.

 

[epidural man]

We are paper charting. A lot of people think "Oh, he won't be involved in his case if he doesn't chart EVERYTHING on a paper chart". I heartily disagree and think that's a crock. The bigger and more involved the case, the bigger the chart looms in the back of your head as you go an hour or two hours or, god forbid, the whole case without getting to chart anything. Then, you drop the patient off in SICU and try and chart a rollback craniotomy from memory. Let's enter the 21th century. We don't need to be sitting down pencilling in every statistic on our patient every 5 minutes. We can rely on technology to have our back a little bit these days and be just as involved with the case. It's a waste of time and takes away from taking care of the pt. Especially in big cases.

Just my .02.

One of my greatest joys doing anesthesia in a small hosptil in ass-crackistan was not charting a thing...just taking care of the patient. That is how it should be.

Also, I would just drop the patient off to the nurse in the PACU, and they would take care of the patient - the understanding was....do your job, take care of what needs to be taken care of, if the patient is cold, warm them up. If they are in pain, give them meds. It was glorious!

Finally, I didn't keep track of my narcotic use! What a joy that was. We all know that keeping track of our 'use' on paper is useless in preventing abuse, so why are we mandated to do that worthless paper drill? (People that are abusing have spotless paperwork anyway. I think the fact that i get a nasty-gram every other day because my paperwork never adds up because I could care less since it is absolutely useless and pointless data - that this should be a signal that I am clearly not abusing - and thus I shouldn't have to keep crunching the numbers...sheesh)

Anyway, when my OIC found out I wasn't keeping track about a month before we left, I had to start doing it...that sucked balls. Also we got a nurse that couldn't function without a "doctor's order" so I had to come up with a PACU order sheet.

(I did chart when I was doing anesthesia on americans just because someone might need that at another facility - but most of my work was on locals that died from sepsis later on when we returned them back to their own hospital because they wouldn't even do dressing changes.....arrrrrghh!!!!)