Sometimes I wonder if people reading my charting notes howl with mirth. I’m pretty sure I would. Example: recently I had an unsatisfying sequence of conversations with a doc, unknown to me previously, with very heavily accented English who was talking on, apparently, a bad cell phone connection. Translation: I couldn’t understand anything. After several episodes of, “Sorry, what dosage? Call back if the value is less than what?” he said, “What’s the matter with you? Do you not English speak?”
I was…mildly annoyed.
Subsequently he gave a crazy order, and while I was attempting to verify I’d heard correctly, he hung up on me. I, again…mildly annoyed, called him back. “We got cut off while I was verifying this order [that is against hospital policy]. Can you verify the order?” He reported the same order and hung up AGAIN before I could again point out that it was against policy and pharmacy would not fill the order. Oh no, he DIDN’T! Oh yes, he did!
Problem. How do I write the order but not carry it out as written while also covering my butt and not writing a bratty, unprofessional charting note?
Solution. “[Drug] ordered to be run over x min. Unable to read back/verify order d/t early termination of conversation by MD x 2; [drug] will be run over x hours per hospital policy.”
“Early termination of conversation”…::snicker::
Sometimes I wonder if people reading my charting notes howl with mirth. I’m pretty sure I would. Example: recently I had an unsatisfying sequence of conversations with a doc, unknown to me previously, with very heavily accented English who was talking on, apparently, a bad cell phone connection. Translation: I couldn’t understand anything. After several episodes of, “Sorry, what dosage? Call back if the value is less than what?” he said, “What’s the matter with you? Do you not English speak?”
I was…mildly annoyed.
Subsequently he gave a crazy order, and while I was attempting to verify I’d heard correctly, he hung up on me. I, again…mildly annoyed, called him back. “We got cut off while I was verifying this order [that is against hospital policy]. Can you verify the order?” He reported the same order and hung up AGAIN before I could again point out that it was against policy and pharmacy would not fill the order. Oh no, he DIDN’T! Oh yes, he did!
Problem. How do I write the order but not carry it out as written while also covering my butt and not writing a bratty, unprofessional charting note?
Solution. “[Drug] ordered to be run over x min. Unable to read back/verify order d/t early termination of conversation by MD x 2; [drug] will be run over x hours per hospital policy.”
“Early termination of conversation”…::snicker::