"Vital signs were taken and documented somewhere in the chart. I have no idea where."
Friday, May 6, 2011
Lost & Found
"Vital signs were taken and documented somewhere in the chart. I have no idea where."
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While reading another doctor's office note this morning I found this line:
"Vital signs were taken and documented somewhere in the chart. I have no idea where."
A Blog detailing the insanity of my medical practice and the stupidity of everyday life.
"Vital signs were taken and documented somewhere in the chart. I have no idea where."
Welcome to my whining!
This blog is entirely for entertainment purposes. All posts about patients, or my everyday life, or anything else may be fictional, or be my experience, or were submitted by a reader, or any combination of the above. Factual statements may or may not be accurate. I could be making all this up. I may not even be a doctor. The only true statement on here is that I probably drink more Diet Coke than you do. A lot more.
Singing Foo!
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Twitter fans- you can follow me @docgrumpy
Cast of Characters:
Annie: My Phenomenal MA
Mary: My Awesome Secretary
Ed: The office fish
Dr. Pissy: The guy I share an office with
Mrs. Grumpy: My Boss (also the world's greatest school nurse)
Frank, Craig, and Marie: The Grumpy Tribe
Garlic and Riley: The Grumpy Dogs
Questions? Comments? Biting sarcasm? Write to: pagingdrgrumpy [at] gmail [dot] com
Note: I do not answer medical questions. If you are having a medical issue, see your own doctor. For all you know I'm really a Mongolian yak herder and have no medical training at all except in issues regarding the care and feeding of Mongolian yaks.
Cast of Characters:
Annie: My Phenomenal MA
Mary: My Awesome Secretary
Ed: The office fish
Dr. Pissy: The guy I share an office with
Mrs. Grumpy: My Boss (also the world's greatest school nurse)
Frank, Craig, and Marie: The Grumpy Tribe
Garlic and Riley: The Grumpy Dogs
Questions? Comments? Biting sarcasm? Write to: pagingdrgrumpy [at] gmail [dot] com
Note: I do not answer medical questions. If you are having a medical issue, see your own doctor. For all you know I'm really a Mongolian yak herder and have no medical training at all except in issues regarding the care and feeding of Mongolian yaks.
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16 comments:
That's a CYA note if ever there was one.
I wonder if that would work for me up front...
"Yeah, I took care of that referral. I sent it...somewhere. I think. Maybe. You're welcome?"
At least the doctor documented.
Sounds like a question for Annie.
Just another example of how great EMRs are.
That way when reviewing the file you know you are not the only one who can't find them!
I bet they are with the Seeker's car title.
My very favorite cranky doctor in the world was kind of an ass sometimes and apparently one of his nurses forgot to write a patient's BP in his chart. Dr C's walls were kind of thin, so I heard him walk into the hall and say "Hey Sunny, so should I just call time of death on Mr Anderson here, because apparently he doesn't have a blood pressure."
Reminds me of a ex primary care doc I fired who asked in shock ‘you were diagnosed with disorder X???’ After I had told him (and he shared with me he’d only had 3 patients so far with disorder X) AND I could see some sheets in my chart with big university logo, a consultation letter that likely stated something about disorder X with in the first three lines.
Documentation fail. That was the moment I realized 1. he keeps terrible office notes and 2. he did not read any of the (at least three) consultation letters the big university docs had sent him.
Send that guy a nicely designed vital signs form he can affix to the front cover of the chart and charge him for the design of the form.
Syndrome x or fragile x disorder? Got me kinda curious...
EHR, right?
I have an inpatient chart/consult that auto-cites a rx from -someone else- that reads "I just want to give the patient a freaking four-footed cane. Why is that so hard?" [This was what was typed in the sig field when "4-footed cane" was not findable in the rx field.]
Written last year on the second day we went to our brand new shiny electronic health record.
Sent electronically to the DME supplier, apparently.
I laughed so hard I peed a little.
That was a Very Bad Weekend (TM).
I printed out the consult note and still use it to torture the ortho who wrote it.
It sounds like the Doctor who wrote that was a wee bit tired, cranky, and taking a passive-aggressive shot at whoever was supposed to take the vitals for the patient for not writing them where Dr. Cranky could find them with just a quick glance.
he is hoping that counts as a bullet for a billing code upgrade. the coders may disagree.
So I guess he did not order them repeated.
You could read his notes?!?
I have that feeling nearly every day trying to review nursing home charts. They document in crazy places, and half the time the documentation is on some random flow sheet in a binder, and not in the chart at all.
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