Have you ever thought about who looks at your charting? Too often, what is written in the chart is thought of in real time only. When we write down our history, our exam, lab values, etc we’re thinking about providing good care to the patient right now. We may, at times, realize that a little later down the road a consultant might need what we’ve written, or something, but rarely are we thinking much further down the road.
You need to change that, and do it now. If you think about the full context of what you’re writing now – in your training – you will form good habits that will stay with you throughout your career. Check this out…
I once received a note I had written 4 years prior (from when I was a resident). It was faxed to me for my review. It turns out that another hospital was being sued by a patient they transferred to my hospital on a night I was on-call. I wasn’t being sued, but they needed my deposition, since I was the first doc to see the patient after transfer was initiated. And even though I wasn’t being sued, I felt nauseated seeing a note I had written years ago come across the fax… from Dewey Soo Em and Howe.
Here’s an incomplete list of (potential) eyeballs on your hospital charting. Please add more in the comments if you think of others…
- Attending physician
- Covering attending physicians – usually on weekends
- Nurse – usually a new one every 12 hours
- Pharmacy techs
- Unit secretaries
- Interns and residents
- On-call coverage, moonlighters, etc
- Coding department
- Billing department
- Utilization review personnel
- Social workers and case managers
- Insurance company reps and reviewers
- Other hospitals’ staff/docs (on future hospitalizations)
- Patients, themselves (Google and Microsoft are both have patient-directed health care records)
- ChartFarts.com (medical charting funnies – whatever you do, don’t end up here)
Be careful with what you write or enter into the computer.