I love taking care of patients.  I don’t mind blood or gore, screaming children or protruding foreign bodies, unpleasant odors or spewing drainage from abscesses.  It’s bread and butter.

But I hate charting!  I especially hate dictating.  I don’t know why, but something inside me doesn’t enjoy doing it.  Consequently, I’m always behind, and tend to get my charts done at the end of each shift.  Or I’m busy and miss the chart, and it shows up in a yellow or red folder days later, handed to me by the long-suffering ladies from medical records.

Call it a character flaw.  Call it procrastination.  Call it ADD.  I don’t know, I just don’t like doing it.  I wish I had a scribe following me from room to room, recording my actions.  Or an orangutan or chimpanzee who could take dictation and dictate for me.  That would be, I suspect, the most enjoyable solution.  ‘I’m doctor Leap and this is Shotzie, our ER Ape.  If he stares at you, look away or he’ll scream.’

On the other hand, I think I hate charting because it’s so unrealistic, so ridiculous now.  We go overboard on everything, and charting is no exception.  So, I can’t just dictate what happened and what I did.  I have to dictate for at least three reasons, and each has slightly different requirements.

I dictate for the medical record, so that we’ll know what to do next time, and what was done before, and so my partners can curse me for giving Percocet to the guy they refused it to last week.

I dictate for medico-legal protection, to demonstrate that I did everything and asked everything necessary for the safety and well-being of the patient; and the ultimate satisfaction of our insurer.

I dictate in order to bill the patient.  And in so doing, I am forced to use an internal medicine template that involves examining the sickest emergency department patients, the ones who are going to be admitted, as if they had stumbled into my medicine office for a new patient visit and need me to document their nose-hairs, crooked joints, liver-spots and spleen size.

This is all ridiculous.  It forces me to document the things that are absent.  That is, in dictating on the chest pain patient, it isn’t enough that his past medical history was negative.  I’m supposed to say, ‘denies heart disease, denies diabetes, denies stroke, denies family history.’  I can’t just say ‘past medical and family history negative.’  Talk about a poor use of space and time!

So, I’m dictating what I actually did, how thorough my exam was, how thorough some lawyers and corporate doctors think it should be, everything I might want to say if I end up in court someday, as well as unnecessary information deemed necessary to prove that I deserve to be paid more than someone hanging drywall.

We do this all the time!  We document the most inefficient way possible.  We record vital signs on young ankle sprains.  We write unnecessary statements that could have been covered by the word ‘negative.’

We do a ‘review of systems’ that has no place in emergency medicine and that could just as easily be covered in ‘history of present illness.’  We have to dictate the indications for our labs and x-rays, which should be adequately covered by the statement, ‘because I said so.’  We say so much that all we do is extend the long legal rope that someone will use to hang us.
But not just doctors, oh no. In a time when we’re short of nurses, and when patients often say they don’t get enough time with those ministers of mercy, regulatory bodies take nurses away from sick humans and plant them, like us, firmly in front of computers.  Our nurses template ‘no drug or alcohol abuse,’ on infants, or ‘non-verbal’ for newborns.  Our nurses document screening exams about nutrition, physical abuse, substance use, immunizations, home medications, medications being sent home and on and on.

Then they drive the dagger home by  documenting their physical exam which frequently conflicts with our own.  I’m glad they like doing exams, and some are good while some are bad (just like physicians) but the potential for each of us to hurt one another in court is very high.
In fact, our nurses document so much, from physician visits to problems reported to physicians, to wasted medicines to ‘patient visited, call light within reach, physician notified of crushing chest pain,’ that I’ve actually seen the reason for the visit lost in the sea of words.

Example:  I have seen patients who came with simple wounds, who came to the ER for a laceration repair and tetanus immunization, but whose chart lacked any description of the wound itself or the repair of said wound.  They were asked about past history, medicines, allergies, family, spouse abuse, alcohol use, and all the rest.  JCAHO did a good job of frightening the nurses about screening.  But the wound?  Described by the nurse?  Hardly.  The wound was a secondary concern to the social engineering being foisted upon hospitals.

(In the larger sense, the sick as a whole are the secondary concern, and lie in the shadow of the looming inefficiency of further social engineering that may visit us next year.  But that’s another topic altogether.)

So, charting makes me crazy.  We waste time and money.  We waste brain cells.  And it could be so simple.

Patient name:  John Doe

Age: 45

Complaint:  Chest Pain

History:  One hour of heaviness in the left chest, radiating to the left arm, with shortness of breath, sweats and nausea.

PMH: Negative

Meds: None

Allergies: None

Family/Social:  Smokes one pack per day.  Father had MI.

Physical Exam:  Vital signs normal

Lungs clear bilaterally

Heart Regular rate and rhythm, no murmur, gallop or rub.

ENT:  No neck mass or JVD

Extremities:  No edema

Abdomen:  Soft, non-tender, no mass

Rectal:  Heme negative

Decision making: EKG showed acute inferior MI.  Aspirin and nitroglycerin drip administered.  No contraindications for thrombolysis.  Chest X-ray negative.  Cardiac markers pending.  TNK administered.  Patient did well, hemodynamically stable, ST elevations resolved, pain free, admitted to CCU to Dr. Heart.

Diagnosis:  Acute inferior MI

Disposition:  To CCU.  Care assumed by Dr. Heart at 1645

Wasn’t that simple?  No nutritional screening, no abuse screening, no reasons for anything I ordered, no nurse’s exam to ambush me later by saying ‘patient had pulsatile mass in abdomen, doctor aware.’  (I was not aware!)

Maybe that’s why I hate charting.  It involves so much charting!  So many extra words, and so little actual useful information.  So, that’s that.  I’ll sign off now.  I probably have some lost charts to dictate.

Quick, hide me!  I hear the medical records lady on her high heels, clicking around the corner with a folder in hand!  Someone document that I don’t feel safe in the ER! And I’m hungry!  Document my nutritional screening!

And be sure to document that I hate, really hate, dictating and charting.

Edwin

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