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Saturday, 18 June 2011

checking nurse's records?

when looking at patient's records, does it make sense to also look at nurse's records?

sometimes, an accurately wrote Nurse's records will help the doctor with the Dx and Rx.

sometimes, there is a discrepancy between patient's actual History of Presenting complaint - "a speck of blood in coughed out sputum" may be recorded "haemoptysis" in nurse's records. - why is this an issue, when the Dr. knows what is going on?

in a case of lawsuit, some people will be so desperate to look for faults in everything they find - a discrepancy between Dr. and Nurse's records are a definite point they would find such  faults. a speck of blood might not need any immediate medical attention - but if this was haemoptysis, it warrants some sort of intervention. the Dr. will be at fault to ignore the "haemoptysis" which never happened!

now, how can Dr.s prevent this happening?
Nurses are not idiots - those kinds of mistakes can be avoided by a more clear explanation, plus a logical flow of thought processes also written into the records - if you suspect this because of that, write it down. "speck of blood in sputum - talked to the patient, found out he was eating lollypops and he cut his hard palate" might help Nurses NOT misinterpreting this as "haemoptysis". etc etc.

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