Monday, March 12, 2012

Charting and Trust

Recording everything we do is very important in the hospital. The saying goes: "If you didn't chart it, you didn't do it." This is not just for legal CYA; it's actually quite important for continuity of care. You wouldn't want a patient to get a double dose of medication, or have a procedure done twice, just because the first time wasn't noted in the chart.

Usually this is a good thing. Yesterday evening, I had a patient complain about it. He piped up just moments after I got report and the day nurse left.

Mr. Scribe: "I gotta say I'm really mad. I kept telling that other nurse I have pain and she wouldn't give me any medication at all. I've been suffering all day and I need my medicine right now!"

Me: "Let me check your chart. It says here that you had a couple of Percocet for pain at eight o'clock, then again at two. Is that not correct?"

Mr. Scribe: "Well, I had those, but that doesn't count. Pills are garbage. I need some of the good stuff."

Me: "I also see that you had IV Dilaudid for breakthrough pain at nine, one, four, and again just a few minutes ago at 6:45."

Mr Scribe: "Um... I guess so. But it's so not fair that you write that stuff down. If you were a good nurse you would trust your patients."


  1. I can just imagine the disappointment this patient felt. :-)

  2. That's about the only thing the patient felt. ;)

  3. I did a stint in critical care once (as a patient). I didn't remember but a snippet of it, so i requested my charts and ho.lee. stool. You chart everything. Everything. I think those nurses that took care of me that week know more about me now than i do.