Buffing the Chart
Buffing the chart is like waxing your car after you wash it. Both will get you where you need to go even if you don't make them all nice and shiny, but a properly buffed chart and a meticulously waxed car are not only things of beauty, they add a bit of protection against the elements too.
Are those vital signs a bit out of the norm? Let's repeat them before we let the patient go. That kid whose mom says "can't keep anything down?" If we see him having a sippy cup/Cheetos midnight snack in the waiting room, you better bet we're going to chart it. The "happy, playful" notation is a personal favorite too. The back painer who "can't walk?" I guess he meant that he couldn't walk unless he needed a cigarette. Or unless he was refused his narcotic of choice. Busted!
Of course, if a patient doesn't agree to any of the CYA tests or advice that we suggest, then we've got to record our discussion in the chart. If a patient would rather accept the 1/10,000 chance that he might die from undiagnosed meningitis than undergo a spinal tap, then who am I to impose my will (and my 3.5 inch needle) upon him? But I have to write a paragraph about it for the attorneys in case his family hits the jackpot.
I would never suggest that anyone write anything in the medical record that wasn't accurate. I can't recall a single instance where I have done so. But we can be a bit selective about what information we choose to include in the record. If the axiom that "if it isn't written in the chart, then it didn't happen" can be used against us, then we can use that principle to our advantage in selected situations as well.
If Dr. Molasses still hasn't gotten around to seeing the patient in bed 8, charting "patient upset about the wait, still awaiting MD evaluation" doesn't help anyone. Charting something like "the ER is very busy with critical patients, patient informed about the delay, offered warm blanket and fluffy pillow" is maybe more useful.
One of my personal irritations is when a triage nurse writes a paragraph for the chief complaint. It's called "chief" complaint for a reason; we don't have to include every little twinge of discomfort the patient has suffered since the Carter administration. "Flu-like symptoms" or "chest pain" are sufficient, thank you. Elaboration in the nurses' notes is always welcome, but let's keep the chief complaint area clean and polished, please.