Wednesday, November 16, 2011
What you need to know and why you need to know it
Medical records used to be a helpful tool to communicate to others what was going on with a patient and how to help pass on their care. The same was true when we signed patients out to each other. A mantra that we used was to be sure we told each other what they needed to know about each patient and just as importantly why they needed to know it. What was different about that patient was immediately passed on. Ms. So and so had a colostomy after a perfed tic, she is stable but she has been on steroids! Nuff said, you knew what to watch for and where to go when things went bad. Her medical records had the pertinent positives and pertinent history. You could pick up the chart, know what was going on and get down to business. Now it is just the opposite. We will have a patient sent in from somewhere. With them will be their records. A multitude of pages that list negatives like "No family history of travel outside of North America. Page after page. You have to sit there and play "Where's Waldo" to catch a glimpse of what is going on with them and pray you find the needle in the haystack. Of course it is all computer generated so you know that someone just clicked on a template so all that is written is BS anyway to comply with some CMS thing and to have "it documented in case of litigation". Its bad enough that it was happening in the paperwork but now it is creeping into direct communication about patients. One of the residents was seeing a patient in the ED and called me to run the case. They started with all the things the patient didn't have. I cut them off and said, "What do I need to know, and why do I need to know it?" There was a pause, then more of the BS about fibro and pain scales. I finally said, "Do they need to go to the OR?" A feeble, yes was the reply. Then I asked "why do they need to go to the OR?". Severe abdominal and back pain with free air and dependent fluid on scan was the answer. "Ok, then. What else is important that I need to know?". Crit is 30, they are probably septic and have afib with a recent stent and an EF of 30%. Crisp, clear, concise. Time for a Bard-Parker Scan!