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|Subject: Re: Waking Up to Major Colonoscopy Bills||Date: 6/1/2012 5:48 PM|
|Author: JLC||Number: 70732 of 77566|
Some time ago there was an anesthesiologist in the Virginia Beach area who did not bother to monitor the blood pressure of his patients while they were under. He just wrote down some good numbers in his report, but never actually took the blood pressure. Finally somebody noticed (why not earlier?), and he lost his license.
I had a couple of attendings in residency training that made comments about recording vitals, etc., during the case. One said, you're not paid to be a secretary, don't get caught up in writing everything down exactly how it goes. Take care of the patient first and write when you can later. Another said, you make the chart up to make the case look like how you wished it went, not necessarily how it actually went.
My own theory of charting. No one else will see this except the workers in medical records (and they are mostly looking to see if everything is signed in the write spot) and potentially a lawyer. Neither of which I care if they can read what I write. But I fall more in line with taking care of patient first, records later.
Personally, I think I have heard of machines that do that and and keep the records themselves.
Those came out while I was in training, so early 90s. Like trying to build something idiot proof, you just build a bigger idiot. We had one for a test drive. You spent more time typing in corrections to erroneous readings that it hurt you more than it helped you. Too many ways to interfere with BP cuff reading (surgeon leaning on it), electrical interference from other machines and the EKG (don't want to spend all case "correcting" a documentation of V fib every 5 minutes), you name it you could mess it up.
That would make the job even more boring.
That's why you download the Words with Friends and Sudoku apps.
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