Stupid Things People Document

[soorg]

I'm all for documenting RELEVANT things on our records, but I've seen some bizarre things being written down at times:

1) What number OR the patient was brought to

2) What fruit the patient is allergic to

3) "Patient's consent was obtained in holding prior to OR"

4) What size IV was started

5) "A full H&P was performed prior to OR"

6) "Patient has prior history of pneumonia." Yeah-25 years ago.

7) "Surgeon complaining patient's heart rate too high-I gave 15 mg of esmolol."

The allergy documentation drives me especially berzerk. I don't care that the patient is allergic to guava pudding or pine trees, but the nurses just love to harp on that crap.

It truly seems at times we're just documentarian monkeys.

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[waterbottle10]

I hate allergy stuff too. Seeing multiple times allergy to epinephrine. And reaction is fast hr

 

[Urzuz]

I'm all for documenting RELEVANT things on our records, but I've seen some bizarre things being written down at times:

1) What number OR the patient was brought to

2) What fruit the patient is allergic to

3) "Patient's consent was obtained in holding prior to OR"

4) What size IV was started

5) "A full H&P was performed prior to OR"

6) "Patient has prior history of pneumonia." Yeah-25 years ago.

7) "Surgeon complaining patient's heart rate too high-I gave 15 mg of esmolol."

The allergy documentation drives me especially berzerk. I don't care that the patient is allergic to guava pudding or pine trees, but the nurses just love to harp on that crap.

It truly seems at times we're just documentarian monkeys.

Agree with most of the things you listed, but I always document the size of an IV that I start. It's just like a surgeon dictating the size trocar used during a laparoscopic case or the size ETT we used -- it's something I'm sticking in the patient (and is actually used after the operation) so I may as well document the size used, location, etc.

Agree 100% about crazy allergies though...I don't give a @&#% that the patient is allergic to ham.

 

[deleted162650]

Some fruit and veggie allergies are also indicative of latex allergy - but it's still a stretch.

 

[dragonark]

Consent isn't a bad thing to document, especially at shops where you don't obtain a written consent for anesthesia....

As for the HR thing...whenever the surgeon asks me to do something I usually document. Even if it's stupid. Especially if it's stupid. Just as a reminder to myself if I ever had to review the record of why I did something, even if it didn't seem necessary.

 

[soorg]

Years ago I had an internist patient tell me with a straight face that she was allergic to epinephrine because it caused "tachycardia." I still can't believe she thought that was an allergy.

 

[IMGASMD]

"I am allergic to epinephrine, it made my heart stop, they had to do chest compression on me." True story.

 

[Noyac]

Agree with most of the things you listed, but I always document the size of an IV that I start. It's just like a surgeon dictating the size trocar used during a laparoscopic case or the size ETT we used -- it's something I'm sticking in the patient (and is actually used after the operation) so I may as well document the size used, location, etc.

Agree 100% about crazy allergies though...I don't give a @&#% that the patient is allergic to ham.

Still, why does the size matter? Just cuz the surgeon does it for trocars?
And for that matter, why does ETT tube matter? BecUse someone might want to know how big of a tube they can place? That's crazy. Just place what fits best. Don't let other smucks determine how you practice.

Another thing, has anyone here ever been sued or heard of anyone sued for a PIV? I haven't. So why do we document this crap?

I even had a pt with a pineapple allergy today. Really? Who cares? Bananas, maybe. But nurses are not smart enough to know the difference.

 

[anbuitachi]

Still, why does the size matter? Just cuz the surgeon does it for trocars?
And for that matter, why does ETT tube matter? BecUse someone might want to know how big of a tube they can place? That's crazy. Just place what fits best. Don't let other smucks determine how you practice.

Another thing, has anyone here ever been sued or heard of anyone sued for a PIV? I haven't. So why do we document this crap?

I even had a pt with a pineapple allergy today. Really? Who cares? Bananas, maybe. But nurses are not smart enough to know the difference.

I do document sizes of IVs, in case something happens, all these are reviewed in M&M. we use compurecord and it only has space for 2 IVs, so I always document in the comments if i place another IV, and I document the size. It takes 2 seconds. It also helps when ppl take over your room, they can always check in the chart the sizes and location of the IVs if previous person forgot to sign it out or the person taking the room over forgets

In terms of ETT size, it matters to me so I dont have to prepare multiple tubes, and it can decrease irritation/trauma to the larynx/cords. why try multiple tubes when you can have a better idea of what worked previously and go with it, and can save time if its difficult. obviously in healthy patients it doesn't really matter..

 

[GravelRider]

It's always better to over-document than under-document. Your thoroughness is a barrier against the lawyers. Bad documentation is a slam dunk for malpractice lawyers...even if you did nothing wrong.

However, I do agree with the allergy nonsense. Who the heck is perpetuating this? Is it laziness by the primary care doctors? Is it just chart lore that gets carried forward? I'm less annoyed by listing actual fruit allergies than I am annoyed by listing medications that made a patient lose her appetite (more often than not, the patient with multiple fake allergies is a female).

 

[deleted162650]

I even had a pt with a pineapple allergy today.

My favorite pt. allergy was back in med school. On the big bold allergy label on the front of the chart:

"Pineapple, Marijuana"

To this day I regret not asking her what her reaction was.

And then there's this classic:

Patient Allergic to Epinephrine, Dies When Doctor Suddenly Slams Door | GomerBlog

 

[Aether2000]

These things matter greatly in a court of law. For instance, in a colon resection, a 22ga IV as the only access would be below the standard of care in a case with potentially significant fluid shifts. Failure to document leaves doubt as to an adequate IV in cases of a poor outcome. Similarly, documenting the specific OR becomes important when equipment in that room could have been implicated in death or injury.

 

[deleted697535]

I can't believe you are complaining about some of those things.
1 Number of or is important. Machine failure or no machine check. Poor ventilation systems for infection control etc etc

Size IV and size et. You think that you shouldn't document this? Have you done any percreta sections? Lady dies with 2 14 guages in vs lady dies with no documented IV cannula size I wonder how that looks. Repeat syndromic kids. It's nice to know what size et fits
I can't even believe you think it's not important to note this.

Well good luck defending yourself bro! I really hope you won't need to. But if you ever have to account for your actions and have nothing written down you're goosed! As we say!

 

[dhb]

Can you use under documentation to your advantage?
Say you do a block then a GA and don't document the block, patient suffers neurological injury. If no block is documented you can't be held reponsible. The patient doesn't remember what happened because he received midaz for the block.

 

[Dejavu]

Can you use under documentation to your advantage?
Say you do a block then a GA and don't document the block, patient suffers neurological injury. If no block is documented you can't be held reponsible. The patient doesn't remember what happened because he received midaz for the block.

You can bet at trial they will be having all the nurses and techs who were present during the block testify about what you did.
From the OP, isn't it a Joint Commission requirement that a current H&P is on the chart before surgery?

 

[narcusprince]

What about documenting the hcg when the nurse already documents it in their note. Its stupid we have to redocument it. This tread should be titled stupid things we redocument.

 

[pgg]

The stupidest documentation is fabricated documentation ... like when someone pre-charts their uneventful emergence, extubation, and PACU signout in the middle of the case, or records BPs of 115/75 like train tracks when they were really ranging from 70/30 to 190/130.

EMRs solve some of this ...

As for recording IV size - it depends. Knee scope? Doesn't matter. Open thoracoabdominal aneurysm? Matters.

I don't get worked up over nurses documenting irrelevant food allergies. Some of them know that some drugs have food components in them. I can't really fault them for being thorough. They know that propofol has egg or soy in it, for all they know Zofran has a delicious blend of pineapple and guava juice in it. Irrelevant allergies are easy to ignore.

 

[waterbottle10]

The stupidest documentation is fabricated documentation ... like when someone pre-charts their uneventful emergence, extubation, and PACU signout in the middle of the case, or records BPs of 115/75 like train tracks when they were really ranging from 70/30 to 190/130.

EMRs solve some of this ...

As for recording IV size - it depends. Knee scope? Doesn't matter. Open thoracoabdominal aneurysm? Matters.

I don't get worked up over nurses documenting irrelevant food allergies. Some of them know that some drugs have food components in them. I can't really fault them for being thorough. They know that propofol has egg or soy in it, for all they know Zofran has a delicious blend of pineapple and guava juice in it. Irrelevant allergies are easy to ignore.

Yea but you aren't going to not give zofran propofol just because they are allergic to those fruits

 

[twoliter]

What about documenting the hcg when the nurse already documents it in their note. Its stupid we have to redocument it. This tread should be titled stupid things we redocument.

I still think it's reasonable to document hcg results (and agree with documenting IV size, tube size, OR, etc.) even if it's documented elsewhere. I don't think we would be faulted for not redocumenting it, though. Think about it. Nearly everything on our preanesthesia eval except airway evaluation is likely documented somewhere: history, physical, allergies, meds, EKG, etc. I don't think it's good enough to check a box that says "chart reviewed, Mallampati 2" for our eval. The paper (or document) is a place to (re)document everything that is important to the anesthetic in one place (sometimes including prior ETT size) on one page. Which becomes even more important when you're supervising a mid level or handing off to someone else.

 

[pgg]

Yea but you aren't going to not give zofran propofol just because they are allergic to those fruits

Obviously not. I'm also not going to not give morphine if the allergy is "happiness" ...

The point is that irritation at the nurses who document these irrelevant allegies is misplaced.

 

[twoliter]

Can you use under documentation to your advantage?
Say you do a block then a GA and don't document the block, patient suffers neurological injury. If no block is documented you can't be held reponsible. The patient doesn't remember what happened because he received midaz for the block.

I can understand how under-documentation can be helpful. Potentially. Really moreso avoiding over-documentation than actually under-documenting. But I'm confused as to why someone would ever not document a block. Are you not planning to bill for it?

 

[deleted697535]

It's not really about giving or not giving the drug. Writing it down means to the judge in 5 year's time that you elicited a thorough history, are aware of the issue re propofol and allergies, understand the latest literature on it and made an educated decision. The fact then that the pt had some unknown reaction means it was a random event and you did all in your power and wisdom to avoid it.

Not documenting it means to the judge you don't know/care anything about allergies and propofol etc and could potentially be seen as negligent.

Exactly by all means don't document needless things. But it requires a lot of knowledge to know what is needless and what isn't!

In our ethics course lawyers tell us if it comes to court and you have a blank anaesthesics page versus an anaestheist page with plenty of text they're more likely to settle in the former. Irregardless the content

 

[deleted697535]

Can you use under documentation to your advantage?
Say you do a block then a GA and don't document the block, patient suffers neurological injury. If no block is documented you can't be held reponsible. The patient doesn't remember what happened because he received midaz for the block.

I really wish this post wasn't here. Can you delete it please from this page and your mind

 

[InfinitiPSI]

^ What he said

 

[bigdan]

Wonder how much the list of "stupid things people document" varies among those who have been sued...

 

[Noyac]

I do document sizes of IVs, in case something happens, all these are reviewed in M&M. we use compurecord and it only has space for 2 IVs, so I always document in the comments if i place another IV, and I document the size. It takes 2 seconds. It also helps when ppl take over your room, they can always check in the chart the sizes and location of the IVs if previous person forgot to sign it out or the person taking the room over forgets

In terms of ETT size, it matters to me so I dont have to prepare multiple tubes, and it can decrease irritation/trauma to the larynx/cords. why try multiple tubes when you can have a better idea of what worked previously and go with it, and can save time if its difficult. obviously in healthy patients it doesn't really matter..

I'm not telling you to stop doing any of this, just that it has very little use. First of all, what is more important, the size of the IV or how well it runs? It may take 2 sec to document but with all the crap we have to document these days, why add to this? It will not save you in a legal issue.
Secondly, I have rarely ever pulled out more than one ETT for a pt with the exception of a double lumen tube. Now if the pt has some sort of pathology like tracheal stenosis then of course it is important but not the 99% of pts we deal with day in and day out.

 

[Noyac]

These things matter greatly in a court of law. For instance, in a colon resection, a 22ga IV as the only access would be below the standard of care in a case with potentially significant fluid shifts. Failure to document leaves doubt as to an adequate IV in cases of a poor outcome. Similarly, documenting the specific OR becomes important when equipment in that room could have been implicated in death or injury.

You will be sued for failure to resuscitate, not for the size of your IV. Document all you want. Im just it is irrelevant. It's the outcome that matters.

 

[narcusprince]

At one of my moonlighting gigs. All you document is asa status mallampati score and method of anesthesia. The rest is canned in from other peoples inputed data. Cerners pre eval takes 60 seconds.

 

[pgg]

Document all you want. Im just it is irrelevant. It's the outcome that matters.

To clarify, you're arguing that documentation of things like IV size doesn't matter. Not that documentation doesn't matter at all. Right?

 

[chocomorsel]

I really wish this post wasn't here. Can you delete it please from this page and your mind

What the heck. He is in Europe. The don't look at doctors as potential lottery tickets like they do here.

 

[deleted697535]

You will be sued for failure to resuscitate, not for the size of your IV. Document all you want. Im just it is irrelevant. It's the outcome that matters.

Being sued is rarely about 1 action or failure to act. It's usually about a series of failures.

I don't know how many times I've missed something and only picked up on it when I was writing my note intraop. Never life and death but still something significant I only picked up on when I started writing.

Writing a lot makes you seem more diligent even if you aren't. Sorry but it's optics

And I'm sorry but if you start a case that's gonna hose with a 20 and indeed the patient duely hoses you will be sued if it goes south despite your subsequent best efforts. Plus even ultrasound cannulating a large blood loss like 3 litres is really difficult.. your initial 'oversight' will be compounded by an infintely more difficult situation.

Just my opinion. I'm no lawyer. Write plenty keep your nose clean. And keeps you off your phone

 

[Urzuz]

Still, why does the size matter? Just cuz the surgeon does it for trocars?
And for that matter, why does ETT tube matter? BecUse someone might want to know how big of a tube they can place? That's crazy. Just place what fits best. Don't let other smucks determine how you practice.

Another thing, has anyone here ever been sued or heard of anyone sued for a PIV? I haven't. So why do we document this crap?

I even had a pt with a pineapple allergy today. Really? Who cares? Bananas, maybe. But nurses are not smart enough to know the difference.

See above for why IV size matters. And people do get sued for IVs. Do a 10 hour case with a tiny IV in the AC, arms get tucked, and liters of fluid end up going into a blown IV and it isn't recognized? Compartment syndrome -> lawsuit (something I heard about that actually happened). Same thing for ETT size, it helps your future partners out to give you a sense for why the things may have gone awry (you place a 6.0 ETT in a 300 lb smoker, peak pressure are high throughout...maybe he was having bronchospasm, maybe your ETT was too small...but at least it provides information). Or, your partner tries to place a large ETT and it doesn't fit, find out the patient has tracheal stenosis and a 5.0 was the biggest that can fit.

I'm not sure why you WOULDN'T document these things, they take all of 5 seconds to do, may provide useful information for your partners, and show thoroughness to fend off lawyers in case things go south. What the hell else are you doing during these cases that is so critical anyway that documenting takes up too much valuable time?

 

[epidural man]

The absolute and most enjoyable anesthesia I ever did was in Afghanistan. Why? Because I didn't document a thing. I took care of the patient.

I dropped them off in the pacu with no orders. Why? Because the experienced PACU nurse was smart enough to know that if the patient was cold, he would warm them up. If they were in pain, he would gave a little pain medication, waited for a response, then gave more if needed. If there was an issue, he came and got me.

It was incredibly liberating.

 

[waterbottle10]

The absolute and most enjoyable anesthesia I ever did was in Afghanistan. Why? Because I didn't document a thing. I took care of the patient.

I dropped them off in the pacu with no orders. Why? Because the experienced PACU nurse was smart enough to know that if the patient was cold, he would warm them up. If they were in pain, he would gave a little pain medication, waited for a response, then gave more if needed. If there was an issue, he came and got me.

It was incredibly liberating.

Sounds like how medicine should be practiced. Did you get paid well

 

[pgg]

The absolute and most enjoyable anesthesia I ever did was in Afghanistan. Why? Because I didn't document a thing. I took care of the patient.

I dropped them off in the pacu with no orders. Why? Because the experienced PACU nurse was smart enough to know that if the patient was cold, he would warm them up. If they were in pain, he would gave a little pain medication, waited for a response, then gave more if needed. If there was an issue, he came and got me.

It was incredibly liberating.

:notsureifserious:

98% of coalition casualties who required surgery and anesthesia were evac'd within 24h ... to places where they got more surgery and more anesthesia. Keeping records and sending them along with the patients is, er, standard of care.

Or were these local nationals that were getting released locally?

We kept the same records for both.

 

[epidural man]

:notsureifserious:

98% of coalition casualties who required surgery and anesthesia were evac'd within 24h ... to places where they got more surgery and more anesthesia. Keeping records and sending them along with the patients is, er, standard of care.

Or were these local nationals that were getting released locally?

We kept the same records for both.

I did about 300 anesthestics. 2 where for british guys, 1 was a marine. I kept records for these three people in cases someone else wanted to see what was done (unlikely though...).

The rest where all afghansitans and no one would ever see or care what I did. We chart for two reasons. 1. To let someone else know what was done. 2. To prevent law suits. Neither of these reasons applied to those 297 other patients.

I will say that about 2 months from the end, our OIC (the surgeon), found out we weren't accounting for opioids like we "should" have been. He did NOT like that. We had huge bottles of fentanyl and were just writing on the bottle the amount we took out each time. Anyway, after that, we had to do some sort of crazy log and stupid SH$T just like we do in the hospital - which is pointless of course because it has ZERO chance of catching or stopping diversion or abuse - but whatever. I did what I was told despite the unbelievable stupidity of it. You would think - if ever there was a place where someone could do what is right, not what is required based on some nurse somewhere who came up with a ridiculous protocol - it would be Ass-crackistan.

 

[dhb]

Did the Afgan have to log all the opium they were producing?

 

[pgg]

I did about 300 anesthestics. 2 where for british guys, 1 was a marine. I kept records for these three people in cases someone else wanted to see what was done (unlikely though...).

The rest where all afghansitans and no one would ever see or care what I did. We chart for two reasons. 1. To let someone else know what was done. 2. To prevent law suits. Neither of these reasons applied to those 297 other patients.

Gotcha. I'm not sure what ever became of the records we kept for local nationals. I doubt they were ever used by anyone after transfer or discharge. The EMRs were probably mined for research projects though.

I will say that about 2 months from the end, our OIC (the surgeon), found out we weren't accounting for opioids like we "should" have been. He did NOT like that. We had huge bottles of fentanyl and were just writing on the bottle the amount we took out each time. Anyway, after that, we had to do some sort of crazy log and stupid SH$T just like we do in the hospital - which is pointless of course because it has ZERO chance of catching or stopping diversion or abuse - but whatever. I did what I was told despite the unbelievable stupidity of it. You would think - if ever there was a place where someone could do what is right, not what is required based on some nurse somewhere who came up with a ridiculous protocol - it would be Ass-crackistan.

The 2nd biggest controlled substance ****-show I've witnessed in my life was what a battalion of Marines did when some morphine autoinjectors came up missing.To this day the only thing I think saved my ass, as the guy ultimately responsible for it all, was that I'd taken the time to engrave serial #s on the autoinjectors with a Dremel to track which were checked out to which Corpsmen. In the end we could actually track the diverter's movements based on which empties were found with which Corpsmen. Person A had the AIs issued to person B who had the ones issued to person C. The guy was stealing them from other Corpsmen and replacing the ones he took with empties (re-capped with the needle broken off). That wasn't sufficient evidence to charge him, though.

I used to moonlight at a place where controlled substances were in a Walmart-grade medicine cabinet behind the anesthesia machine. Even had cocaine solution.

The other day I was actually spot checked in the OR. Some guy came in with a handheld device, took two drops from my midazolam syringe, and said, yep, it's midazolam, have a nice day. Not sure what would've happened if the machine didn't tell him it was midaz 1 mg/mL.


So much variability in enforcement, accounting, and consequences. We ought to just disband the DEA, de-schedule everything, and quit pretending to care.

 

[soorg]

I'm all for documenting RELEVANT things. I do note PIV size in cases with potential for blood loss. ETT size always good. Any type of medical/cards clearance always. Padding of pressure points.

The OR number isn't relevant. If the patient makes it through the procedure without incident then clearly there wasn't any equipment/ventilator failure.

I understand the idea behind careful documentation, but who's to say documenting every little thing will save you? It may even work against you. "Doctor, I see you've very carefully documented the patient's eye color and BMI-why is that? Are you trying to hide something?"

Yes, a current H&P by the surgeon is required. Not documentation that an anesthesiologist did a full H&P him/herself.

 

[Noyac]

To clarify, you're arguing that documentation of things like IV size doesn't matter. Not that documentation doesn't matter at all. Right?

Correct

 

[epidural man]

Gotcha. I'm not sure what ever became of the records we kept for local nationals. I doubt they were ever used by anyone after transfer or discharge. The EMRs were probably mined for research projects though.






The 2nd biggest controlled substance ****-show I've witnessed in my life was what a battalion of Marines did when some morphine autoinjectors came up missing.To this day the only thing I think saved my ass, as the guy ultimately responsible for it all, was that I'd taken the time to engrave serial #s on the autoinjectors with a Dremel to track which were checked out to which Corpsmen. In the end we could actually track the diverter's movements based on which empties were found with which Corpsmen. Person A had the AIs issued to person B who had the ones issued to person C. The guy was stealing them from other Corpsmen and replacing the ones he took with empties (re-capped with the needle broken off). That wasn't sufficient evidence to charge him, though.

I used to moonlight at a place where controlled substances were in a Walmart-grade medicine cabinet behind the anesthesia machine. Even had cocaine solution.

The other day I was actually spot checked in the OR. Some guy came in with a handheld device, took two drops from my midazolam syringe, and said, yep, it's midazolam, have a nice day. Not sure what would've happened if the machine didn't tell him it was midaz 1 mg/mL.


So much variability in enforcement, accounting, and consequences. We ought to just disband the DEA, de-schedule everything, and quit pretending to care.

Actually, testing the syringe sounds like the smartest thing to do. Just randomly test syringes, and leave all of the accounting crap behind. What is in the syringe matters more than anything anyway. Actually - drug testing probably matters too - but that is way too expensive, so instead, I spend 15 minutes a day making sure all the numbers match up.

the other thing I find strange - is if I am using...my documentation will be impeccable. Doesn't that right there prove how silly the documentation is?

 

[pgg]

Actually, testing the syringe sounds like the smartest thing to do. Just randomly test syringes, and leave all of the accounting crap behind. What is in the syringe matters more than anything anyway. Actually - drug testing probably matters too - but that is way too expensive, so instead, I spend 15 minutes a day making sure all the numbers match up.

the other thing I find strange - is if I am using...my documentation will be impeccable. Doesn't that right there prove how silly the documentation is?

It sure is silly.

I think testing syringes isn't real useful either though. Same case, I'd pulled 1000 mcg of fentanyl too, but I'd already used it all and the syringe was empty. Nothing trjere for him to test. Testing unused drugs or leftovers won't catch diversion when the drug is documented as given to a patient.


The way to detect diversion early is for the pharmacy to track controlled substance usage by person, and look for trends.

Diversion by anesthesiologists and CRNAs results in escalating clinical use of the drug. It is OBVIOUS from pharmacy data, and this is an EARLY indicator. Real life example from the biggest controlled substance ****-show I've witnessed in my life:

This person wasn't caught diverting until Feb 2011 because no one was tracking individual use of drugs. Hell, the pharmacy didn't even blink when they had to start refilling the Pyxis daily. (Seriously guys, WTF?)

I got tasked with reviewing all his charts for the previous 2 years and it blew my mind how obvious the diversion was, 4 whole months before he was caught. If only anyone in pharmacy had been looking.

He's probably have been caught by his next peer review (chart review) cycle too, which I think was due in March or April. He was routinely documenting 2 or 4 mg of hydromorphone for colonoscopies.

Never failed a drug test. Never had a single accounting error in his charting. Very smart, high functioning guy.

 

[epidural man]

It sure is silly.

I think testing syringes isn't real useful either though. Same case, I'd pulled 1000 mcg of fentanyl too, but I'd already used it all and the syringe was empty. Nothing trjere for him to test. Testing unused drugs or leftovers won't catch diversion when the drug is documented as given to a patient.


The way to detect diversion early is for the pharmacy to track controlled substance usage by person, and look for trends.

Diversion by anesthesiologists and CRNAs results in escalating clinical use of the drug. It is OBVIOUS from pharmacy data, and this is an EARLY indicator. Real life example from the biggest controlled substance ****-show I've witnessed in my life:

This person wasn't caught diverting until Feb 2011 because no one was tracking individual use of drugs. Hell, the pharmacy didn't even blink when they had to start refilling the Pyxis daily. (Seriously guys, WTF?)

I got tasked with reviewing all his charts for the previous 2 years and it blew my mind how obvious the diversion was, 4 whole months before he was caught. If only anyone in pharmacy had been looking.

He's probably have been caught by his next peer review (chart review) cycle too, which I think was due in March or April. He was routinely documenting 2 or 4 mg of hydromorphone for colonoscopies.

Never failed a drug test. Never had a single accounting error in his charting. Very smart, high functioning guy.

Wow! Good share. Thanks.

 

[apoondoc]

I'm old enough to remember when the chart was used for physician-to-physician communication. Notes were quick and to the point.

Now the charts are meant never to be read, except by an attorney. It's all noise, and no signal.

 

[narcusprince]

Wow! Good share. Thanks.

He has shared this before......

 

[Planktonmd]

All this documentation of silly and stupid things comes to anesthesiology from nursing. This is what nurses are forced to do all day long: enter stupid crap that no one ever reads in computers.

 

[No_Pain]

What do you all write in the comment section in the anesthesia record during a routine case? ASA monitors applied, slow controlled induction, extubated awake following commands TV > 200mL, transported to PACU on O2 without complication etc..?

 

[anbuitachi]

What do you all write in the comment section in the anesthesia record during a routine case? ASA monitors applied, slow controlled induction, extubated awake following commands TV > 200mL, transported to PACU on O2 without complication etc..?

well its on compurecord for us so we just check some boxes. We have to document all procedures (a line, central line, blocks). we document intubation comments (blade used, grade view), preop comments (sedation in holding or not, IV, prehydration, etc) , positioning commends, and sometimes extubation comments

 

[Fajardo04]

You will be sued for failure to resuscitate, not for the size of your IV. Document all you want. Im just it is irrelevant. It's the outcome that matters.

In residency, we had a case (not mine) where the plastic cannula broke off of the tip of the IV post-operatively and migrated into the pulmonary vasculature where it permanently lodged. Interventional radiology did not think it was worth the risk to retrieve it, especially since it was a "small catheter" and likely wouldn't cause a major obstruction. What constitutes a small catheter in this scenario is likely up for debate, but I would find it hard to imagine a scenario where a plaintiff's attorney would not jump all over you if you didn't document the size of the IV you put in. Although rare, stuff like this happens. Documentation in these cases is your friend if you use it.

 

[pulmoblast]

The best documentation is by opthal and ortho...it's like looking at the matrix computers on the Nebuchadnezzar


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