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.
posted by scalpel at 3:42 PM
22 Comments:
"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."
Very good point. Never thought about the idea of "reverse buffing" by writing less.
Reverse buffing is a very important skill. Know when to shut up.--particularly when Lawyers are involved.
Oh, hell yes I write "Pt instructed to remain NPO pending MD eval" and later "Has not vomited 16 oz. bag of Cheetos and 32 oz. cola consumed in waiting room despite above instructions".
Found your blog through MonkeyGirl and Nurse K.
You're fuuuunnnnny!! I like your ripping comments about The Dawn. I've got her pissed off at me now, but I'm gonna take her down....a notch or two.
Buffing the chart - that's good, I likee.
When I'm in triage, I try my best to try to not lock the MD into some sort of eval...like "Pt here with right-sided abdominal pain, sent to ER from her clinic for further workup" vs. "sent to ER to rule out an appy."
Good advice, epecially when some parasites (lawyers) make insane salaries crushing good health workers on stupid charges.
Oh, I just wrote a post called "Letting Mark Down" and I linked to you in a creative way. (I had you treat an infected fight bite in a homeless man.)
Buffing the chart - so true!
Unfortunately when you get behind, it's hard to always remember all that you offered/instructed the patient (and all they refused!). Echodoc
Given doctors' strategic use of the medical record, it is absolutely imperative that patients secretly tape record all their interactions with physicians. Further, patients should utilized their rights under HIPAA to amend records when they are faulty. Doctors are out to get their patients; we must protect ourselves!
what's the difference between flu-like symptoms and flu symptoms?
I appreciate nurses like Nurse K who do not pigeon-hole us with their documented chief complaint. There's nothing worse than getting a headache patient (who is probably having a migraine) and the nurse writes on the chart "worst headache of her life" or "has neck stiffness". Argh.
Also, to Anonymous. Are you kidding? If not, then you have NO IDEA. As doctors we aren't trying to "strategically use the medical record" to harm the patients. We are only protecting ourselves from ridiculous lawsuits and greedy patients.
anon 1900,
Don't mind then if I videotape your rectal and pelvic exam to document that it was done. Also follow you to the pharmacy and home to see that you took your medications as instructed. Also to document that you are following dietary, smoking, alcohol, and exercise instructions
"Doctors are out to get their patients; we must protect ourselves!"
I have never sued a patient.
Sounds shady to me!
More lunacy from unhinged doctors. As a patient, I pay for your services; if I want to tape it (or videotape it), the customer's always right.
you guys always say, "Oh, we only "buffing the chart"--i.e, LYING to protect ourselves. We would NEVER hide an actual mistake. It's all the greedy lawyers fault. Who are you kidding, but yourselves, and the patients whose fear of death and morbidity you so skillfully manipulate so as to render complacent.
The entire medicine debate reeks of the Stokholm syndrome.
I have recently been accepted to med-school and I am hoping someone will be kind enough to lend some advice. Before I started applying to med-school I was thinking mostly about the positive aspects of the profession and thought I had a decent handle on most of the negatives. But, after reading several medical blogs for the past few months, I am discouraged. I read about the litigation and the seemingly endless stream of comments from people that think doctors are overpaid and out to get them. People like anon 1900 really scare me. I can't believe the number of stories I've read about ridiculous claims and now the Ritter case. With a huge amount of money and years of my life to spend in pursuit of a medical education, I have to ask, "Is it still worth it?" I really can't imagine myself doing anything else, but I don't want to end up in financial ruin with only the adversarial interactions with my patients to remember. What would you say? Become a doctor or go into something else?
Oh it's still worth it. There are so many patients and colleagues who make it all worth while. Medicine is still fascinating. I think some of what you are seeing is blowing off steam. You have to be so P.C. at times, even when dealing with the occasional abusive troll patient, so those who blog write about those interactions.
Scalpel just happens to write about it in a funny and interesting way. ;)
Are there huge stressors and challenges? Yes.
It's a lifestyle, so don't go there unless you are willing to live it. Echodoc
I don't advocate lying. But I do advocate remembering that the medical record is a powerful document that should be handled delicately and with precision.
And yes, it's still worth it. The positives far outweigh the negatives. The positives just aren't as fun to write about.
So you aren't lying when someon'e BP is dangerously high, you just keep taking it over and over again until you get the number you like and thats what you chart? How is this not lying? You are manipulating the real issues.
Anonymous has apparently had a bad experience. Sorry to hear that. Instead of trolling on medblogs accusing everyone of medical malpractice why don't you write about your own experience and get it off your chest?
If you were able to read without the veneer of rage you would see the Scalpel has not advocated dishonesty.
And we sometimes take the blood pressure over a few times because it is often briefly elevated from stress, pain and anxiety. If it is indeed truly trending down it's better not to start a new blood pressure medicine for this transiently high BP. That's not dishonesty - it's good medical practice.
Otherwise tomorrow when the patient is no longer in pain or distress his BP will be in the toilet from the unnecessary BP medication.
Echodoc
as a patient appreciate the info-want to get good care efficiently. maybe prev anon poster will soon learn about white coat syndrome etc- taking vitals a few times allows for filtering out response to stimulus of Dr office and othor stressors. i know my compliance and ability to describe symptoms accurately goes up with doctors who show some sympathy. keep blowing off steam and keep helping your patients get well.
Old blog...is anyone reading this still?
If so, my concern is buffing the chart for upcoding purposes. I'm a physician and have been to the ER myself a couple times over the past 15 years. Each time I reviewed the ER doc's records at a later date and each time the charts were buffed.
Example: last time I went to the ER with a kidney stone. The ER doc's chart notes ran through a complete physical exam...everything from heart/lung assessment to cranial nerve review.
Unfortunately, the only time the doctor touched me was to shake my hand at the conclusion of the visit.
I think this sort of thing is very common. Though we all give lip service to the "never tell a lie" mantra, in fact, for many of us wnl means "we never looked" rather than "within normal limits".
Charts are buffed everyday, and I believe we are far less honest than we say we are.
I went to the ER recently as a patient, the doctor documented a head to toe exam, but the only time he touched me was to shake my hand at the conclusion of the visit.
In a world where a buffed chart pays big money, and where wnl means "we never looked", buffing is a daily occurrence.
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