Long time, no blog. No excuses, just life.
I was reviewing a patient's chart this morning, and several phrases in nursing/physician notes caught my attention: Patient refused breakfast. Patient denies shortness of breath.
If you're a hospital caregiver, you've seen similar stuff written on charts. Wording notes this way makes it sound like patients are our adversaries. Like we're suspicious of what they say and do. Like the little sneaks can't be trusted. (Oh, he denied shortness of breath, but I think we know better. Refused breakfast, did he? Well, we'll just see about that!)
I've also seen people refer to themselves in progress notes as "The writer" rather than saying "I", as in "The writer observed the patient performing self-care", instead of "I watched Mr. Jones perform self-care." What's the reason for that? Is "the writer" somehow more professional and credible? I also wonder why people write "Patient stated" or "Patient verbalized" rather than "Patient said".
And, if you're a patient, don't ever dare to leave the hospital "Against Medical Advice". If that gets written on your chart, you're branded as an uncooperative jerk.
Which you may be.
But, you may also have needed to deal with an urgent personal matter, and your doctor didn't see fit to make ward rounds and write your discharge order at a reasonable time. "Uncooperative jerk" cuts both ways. " Discharged self AMA" sounds like we're running prisons rather than hospitals.
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If you're a hospital caregiver, you've seen similar stuff written on charts. Wording notes this way makes it sound like patients are our adversaries. Like we're suspicious of what they say and do. Like the little sneaks can't be trusted. (Oh, he denied shortness of breath, but I think we know better. Refused breakfast, did he? Well, we'll just see about that!)
I've also seen people refer to themselves in progress notes as "The writer" rather than saying "I", as in "The writer observed the patient performing self-care", instead of "I watched Mr. Jones perform self-care." What's the reason for that? Is "the writer" somehow more professional and credible? I also wonder why people write "Patient stated" or "Patient verbalized" rather than "Patient said".
And, if you're a patient, don't ever dare to leave the hospital "Against Medical Advice". If that gets written on your chart, you're branded as an uncooperative jerk.
Which you may be.
But, you may also have needed to deal with an urgent personal matter, and your doctor didn't see fit to make ward rounds and write your discharge order at a reasonable time. "Uncooperative jerk" cuts both ways. " Discharged self AMA" sounds like we're running prisons rather than hospitals.
