Stupid Things People Document

[Noyac]

Here's another stupid thing we document:
-The time it took to perform a block. So what if it took 5 min of 12 min. If it was difficult and took longer then usual it doesn't matter because if it worked nobody is concerned but if it didn't and even worse if it injured the pt, it doesn't matter if it was short or long. You are still at risk for a suit. So why chart the time?

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[deleted162650]

Here's another stupid thing we document:
-The time it took to perform a block. So what if it took 5 min of 12 min. If it was difficult and took longer then usual it doesn't matter because if it worked nobody is concerned but if it didn't and even worse if it injured the pt, it doesn't matter if it was short or long. You are still at risk for a suit. So why chart the time?

The only time it really matters is if I'm doing the block in the OR once the "anesthesia start" clock has already started running on the electronic record. You can't bill for the post-op pain block and anesthesia time concurrently so my block time gets subtracted from my anesthesia time. All my blocks take less than 5 mins

 

[waterbottle10]

The only time it really matters is if I'm doing the block in the OR once the "anesthesia start" clock has already started running on the electronic record. You can't bill for the post-op pain block and anesthesia time concurrently so my block time gets subtracted from my anesthesia time. All my blocks take less than 5 mins

What's your technique on aspirating/injecting local while holding probe and needle? It feels hard on the hand

 

[deleted162650]

What's your technique on aspirating/injecting local while holding probe and needle?

Someone else does the injecting - whoever is near by. Nurse, PA, Anes tech, partner - doesn't matter.

It feels hard on the hand

That's what she said

 

[fakin' the funk]

What's your technique on aspirating/injecting local while holding probe and needle? It feels hard on the hand

35ml syringe on a 18g Tuohy. Ultrasound with one hand, aspirate and inject with the other. Seeing your needle tip and spread of local > aspiration, to detect vascular puncture.

I trust no one.

 

[deleted162650]

Or you can get exotic. Hold the block needle between your thumb and middle finger with the syringe in your palm. Use your index finger to push the plunger down and up to inject/aspirate.

 

[Aether2000]

That "stupid crap that nobody reads" can save your ass in court. Don't think for a second that any box left unchecked will not come back to haunt you during litigation as evidence of callous malpractice. Every entry, no matter how small, will be scrutinized by an entire legal team that includes another anesthesiologist who will find your charting sloppy and careless, demonstrative of the manner in which you deliver anesthesia. You will be grilled for hours in depositions and in court about all the documentation you did not do.

 

[Noyac]

That "stupid crap that nobody reads" can save your ass in court. Don't think for a second that any box left unchecked will not come back to haunt you during litigation as evidence of callous malpractice. Every entry, no matter how small, will be scrutinized by an entire legal team that includes another anesthesiologist who will find your charting sloppy and careless, demonstrative of the manner in which you deliver anesthesia. You will be grilled for hours in depositions and in court about all the documentation you did not do.

Maybe so.
Then why don't we move the stupid boxes?
We agree that they are stupid, right?

 

[pgg]

The chart isn't there for us any more.

It's there
1) so that billing companies can get most of the money from insurance companies with the least amount of fuss
2) to keep the soulless bastards at JCAHO and CMS at bay by proving compliance with whatever flavor-of-the-week rule they conjure

The days of the chart being primarily a tool for doctors to communicate with doctors are long gone. I remember as a med student writing SOAP notes on paper and learning how to effectively document and communicate what the patient said, what I saw, what I thought, and what I was going to do. If you weren't concise your hand hurt and you learned to be more concise. If you did a lousy job and didn't communicate well, the poor intern or resident had to redo your work instead of cosign it.

The EMR has very nearly killed that approach to note writing.

I can document placement of a central line or an epidural with free text in a couple of human-readable lines that effectively communicate what I did to any reader. But then payment will be denied because my note missed some keyword regarding site marking, wristband checking, ceremonial CMS pre-procedure chanting, the kind of clothing I was wearing, or if I waited N seconds for the prep to dry. Instead I'm stuck clicking literally dozens of boxes.

It's an easy way to document. But it makes the documentation useless to everyone else except the billing company and the aforementioned inbred JCAHO and CMS cretins, because it's not human readable and it's diluted with irrelevancies.


A cynic might add
3) So that midlevels can more easily practice "at the top of their licenses" by removing thought, understanding, and the need for effective communication from their documentation requirements. Monkey charting for monkey skills.

 

[fakin' the funk]

The chart isn't there for us any more.

All great points.

When you see a good or thoughtful note it makes it all the more remarkable.

I overheard a surgery resident telling the med student "yes, the vitals in your note need to be updated every day. No, they don't autoupdate every day. Yes, you have to right-click, then..." So sad

 

[turnupthegas]

I walked in the holding area for L and D once and interviewed a patient with an allergy wristband the nurses had given her. I inquired as to what the allergy was to which the patient politely and seriously responded, "Snakes. They make me itchy."

The nurses documented this and gave her her a DAMN wristband. SMH


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[deleted162650]

I walked in the holding area for L and D once and interviewed a patient with an allergy wristband the nurses had given her. I inquired as to what the allergy was to which the patient politely and seriously responded, "Snakes. They make me itchy."

The nurses documented this and gave her her a DAMN wristband. SMH


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Hey at my shop the patients get allergy wristbands that say "NKDA". No bullsh*t.

 

[Monty Python]

Saw this one recently with one of our more portly attendings:

"Surgeon requesting room temp lowered due to excessive sweating. Surgeon informed of Pt temp 36"

Then like every fifteen minutes:

"Surgeon again reminded of temp. Surgeon continues to sweat and request room temp lowered"

I will chart this ^^^ under similar circumstances, especially if I'm using all available modalities to keep the patient normothermic. I'm not going to take a bullet if the PACU arrival temp mandates an incident report be written by the PACU RN. My hospital has tight tolerances on that (I think it's one of the current Medicare "quality" standards which are reported ... I think.)

And while some might disagree, I think charting the specific OR # is important. We noticed a spike in post-op infections; someone did good retrospective data review and discovered the infections were centered primarily on three specific ORs (out of 11 ORs in the suite). These three ORs were cleaned by one particular new housekeeper, who had been rushed into unsupervised duty status without proper mentoring. Without knowing the specific OR #s this problem might have gone unsolved.

 

[OB1🤙]

Block time matters, even if done preop, if the block is the primary anesthetic. That's cash money, yo.

If it's a postop pain block then the time doesn't matter one bit.

 

[Ignatius J]

The only time it really matters is if I'm doing the block in the OR once the "anesthesia start" clock has already started running on the electronic record. You can't bill for the post-op pain block and anesthesia time concurrently so my block time gets subtracted from my anesthesia time. All my blocks take less than 5 mins

Pretty sure you can bill for time doing the block. I will need to double check as I could be wrong, but but I thought anesthesia time is anesthesia time, be it a block in pre-op, OR, or PACU.

 

[pjl]

Pretty sure you can bill for time doing the block. I will need to double check as I could be wrong, but but I thought anesthesia time is anesthesia time, be it a block in pre-op, OR, or PACU.

Only if block is primary anesthetic. If you are billing for post op pain control, you need to subtract out if done in OR. Otherwise it is double dipping.


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[fakin' the funk]

Only if block is primary anesthetic. If you are billing for post op pain control, you need to subtract out if done in OR. Otherwise it is double dipping.

You can only bill for postop analgesia, or for the anesthesia time of doing the block, not both.

If you are a Jedi trained in the ways of knowing your pt's insurance payer and what they pay for and what they deny (some deny for TAP blocks, eg), you might be able to maximize your units.

Otherwise I just bill for postop pain and eat the 4-6 minutes

 

[periopdoc]

• Ins and Outs for carpal tunnel release and similar cases
• Patient temp in PACU for endoscopies and other 15 min cases
• Witness controlled substance waste
• Signing anesthesia consent
• Transcribing times and other info from my computerized record onto a sheet of paper so that the nurse can enter it into her computerized record
• Nurses documenting fetal heart tones while I'm putting an epidural in, before dosing it

Thankfully, my hospital doesn't participate in JCAHO so I don't have to put up with their B.S.

 

[WholeLottaGame7]

• Ins and Outs for carpal tunnel release and similar cases
• Patient temp in PACU for endoscopies and other 15 min cases
• Witness controlled substance waste
• Signing anesthesia consent
• Transcribing times and other info from my computerized record onto a sheet of paper so that the nurse can enter it into her computerized record
• Nurses documenting fetal heart tones while I'm putting an epidural in, before dosing it

Thankfully, my hospital doesn't participate in JCAHO so I don't have to put up with their B.S.

Agree with all of the above. Maybe would document fluids since it's a drug (and 500 vs 1000 might matter in a HF patient), but having to chart 2 of EBL is ridiculous. In residency I would just start making **** up when surgery residents would ask. "How much EBL? 9.4mL. What, did you think we were going to need to transfuse blood for this lap appy?"

 

[Domperidone]

Speaking of being a documentarian monkey...
I once had a paranoid/highly anxious patient with a banana allergy.

something like a back rash was the reaction.
I didn't bother documenting it initially. When she got banana yoghurt (which may or may not have real bananas) I had to go back and re-document it before she started thinking we were trying to kill her. she was already secretly recording some of the conversations she was having with staff before she was found out. Other things I've seen include pomegranate. As if we would ever have anything that fancy in a hospital meal.

 

[epidural man]

Thankfully, my hospital doesn't participate in JCAHO so I don't have to put up with their B.S.

Lucky bastard.

There is only one body of regulators I hate more than the FDA - and that would be the JC.

I don't understand why more hospitals don't kick JC out.

 

[GravelRider]

If we didn't check all those boxes and document everything then how would we capture all the necessary information for our PQRS, ACO, or any other alphabet soup du jour?

My biggest problem with the joint commission (aside from the fact that they are a completely useless organization) is the amount of distraction they cause when they visit and the weeks leading up to that visit. It is actually at a point where I think it is unsafe for patients to seek care at a hospital during a joint commission visit.