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the complexity of health care |
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the many people on a health care team |
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the development of standards of care by
professional groups |
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the increasing ability to communicate
quickly and easily electronically |
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the desire of professionals to carry out
multi-site outcomes research |
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the requirement to prove to third party
payers the need for services |
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the litigious nature of our society |
People tend to believe written information. In this
course we will look at methods used to purposefully distort a message to sell a product or
an idea.
Because client's lives can depend on an accurate medical
record, this distortion of facts must not occur in a patient's chart.
A medical record is bound by ethical considerations to
present facts as they are, and record events as they happen. The legal system takes the
stand that information in a medical record is true, and that events not recorded did NOT
happen. This demand for the nurse to record every assessment and intervention resulted in
ever increasing hours spent working on nursing documentation.
This took the nurse away from the bed side, actually
reducing nurse-client time. In intensive care areas nurses simply cannot leave the bedside
to do extensive documentation. The pace is so fast that information not recorded
immediately can be easily forgotten. It is not at all uncommon to see a nurse in scrubs
with vital signs scribbled down both legs. Committees of professionals went to work to
find ways to document essential care without writing it all down. Flow sheets, care maps,
and written standards of care for specific client groups are the current answer to this
demand. Computerized assessment and care records requiring a nurse to use computers inthe
nurse's station help somewhat. Hand held computers allowing data entry in the client's
unit is a major step in streamlining the creation of a medical record.
Physicians, nurses and other health care professionals
are taught what to assess, how to record it, what care to give and how to record that.
Professionals are appropriately focused on writing what they should. Nurses are also
focused on reading the doctor's order sheet. The attention that every team member gives to
the narrative entries of others into the chart is highly variable. Just as listening is a
vital part of any verbal interaction, reading is a vital part of working with a written
record. Nursing students are expected to read their client's chart so that they have the
benifit of the entries of other members of the health care team.
Here is a hyperlink to an actual
written exchange which, while funny, points out how written communication falls apart
without careful reading.
