* * Anonymous Doc: When Notes Go Rogue

Friday, January 25, 2013

When Notes Go Rogue

I round on my patients pretty early in the morning.

So I was surprised to see that three of them already had cardiology notes in the system before I saw them.

Patient 1 was "feeling better."

Patient 2 was "feeling better."

Patient 3 had refused a paracentesis.

So I went to see them.


Patient 1:

"So, I saw that you're feeling better."

"Me?  No.  Chest pain."

"But you saw the cardiologist this morning and he said you were feeling better then?"

"No.  The cardiologist?  Today?  Nope.  Haven't seen him."

"You're sure?"

"Yep.  And this pain?  Since last night."

"The cardiologist should definitely see you then."

"If you say so."

"And you're sure he hasn't?"

"Yep."


Patient 2:

"So, I saw that you're feeling better."

"Yep, definitely."

"Great.  And you saw the cardiologist this morning."

"Nope."

"You're sure?"

"Yep.  I haven't seen a cardiologist at all, I don't think."

"No, you saw him yesterday, didn't you?  Tall guy, mustache, gray hair?"

"Nope."

"You're sure."

"Yep."


Patient 3:

"Did I hear that you refused a test?"

"No."

"Something called a paracentesis?"

"Yeah, I had that yesterday afternoon.  Do you have the results?"

"I have to check... but, uh, I was told you refused it."

"No, I didn't refuse anything that I was supposed to have."

"Did you see the cardiologist this morning?"

"This early?  No."

"Okay.  I'll check on the test results."

3 comments:

  1. Sounds more like the cardiologist went rogue!

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  2. That is unfathomably unconscionable and unethical!

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  3. How odd! I could see the cardio doc writing "fine" in the notes to avoid rounding, but the refusing a test thing would be an odd thing to make up. Please post an update when you speak to the other doc!

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