Friday, May 6, 2011

Lost & Found

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."

16 comments:

Anonymous said...

That's a CYA note if ever there was one.

kate said...

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?"

Jon said...

At least the doctor documented.

Mal said...

Sounds like a question for Annie.

ndenunz said...

Just another example of how great EMRs are.

Nectarine said...

That way when reviewing the file you know you are not the only one who can't find them!

Kim said...

I bet they are with the Seeker's car title.

Ellie said...

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."

Outre said...

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.

Anonymous said...

Syndrome x or fragile x disorder? Got me kinda curious...

Anonymous said...

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.

I.P. Sittingdown said...

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.

Anonymous said...

he is hoping that counts as a bullet for a billing code upgrade. the coders may disagree.

ERP said...

So I guess he did not order them repeated.

Jacob said...

You could read his notes?!?

Anonymous said...

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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