The magical mystery land of community health

I don't make this stuff up!…but I do change identifying information.

I hate you, documentation March 11, 2008

Filed under: Uncategorized — lesbonurse @ 1:57 am

Right now I shudder to think about my desk at work.  This is because I have 23 charts stacked on my desk.  The charts are sitting, lurking and waiting to torture me with their endless documentation requirements.  This morning I woke up and as soon as my eyes opened I thought “God, I have all those charts to do!”  I do believe that my life would be easier if I didn’t have to use our stupid electronic record system for my notes.  I have the choice of making eye contact with my patients and focusing on them during the visit, or attempting to write my notes on the computer during the visit while mumbling “mmmhmmmm” and simultaneously forgetting whatever the hell they’re saying.  I choose to pursue the avenue of deep eye contact and reflective listening, which inevitably ends with me piling the unfinished charts on my desk and praying for a few extra moments at the end of the day so I can write my notes.  Several of my colleagues have taken the approach of using pre-written templates for their exams.  I recently came across a note for a male physical exam which clearly had been pre-written.  Why do I think this?  Because the genital section of the exam included a detailed description of the patient’s vagina and cervix.  Oops.  I also saw a note from another provider that listed the general appearance of the patient as “obese”–though the patient weighed 90lbs.  Although I feel proud that my notes are always detailed (and frequently feel grateful to myself for writing things down since my memory sucks), I wish they didn’t take so goddamn long.