Something bizarre happened to me recently which I'm still trying to wrap my head around. Here's the gist of it:
I got a call about a patient that sounded a bit dodgy, so I went and checked him out and came to the conclusion that he might have condition X, but the decision about this and any subsequent management was in any case above my pay grade, so I called the X-ology registrar.
There was a fair bit of back and forth involved with this registrar, but here are the lessons that he imparted to me, along with some sarcastic interpretive remarks by yours truly:
- If you suspect that a patient has a serious medical condition, don't document this in the notes, because if you do, the relevant expert will have to review the patient rather than simply dismiss your concerns out of hand over the phone.
- If you do get the relevant expert to review the patient, don't document this in the notes. Instead, you should document their findings and recommendations as your own, because clearly an intern is the guy whose opinion you should trust about this stuff.
- Similarly, do not mention to anybody else on your team that you are getting the relevant expert to review the patient, or the long-suffering expert will be forced to write his own documentation and actually sign it, and ink is expensive these days.
- When you are documenting things, write as little as you can, or even less, or else people will think you are incompetent or retarded or trying to hide something. It will also ensure that subsequent clinicians will be able to start afresh in their own assessments, free from bias or preconception.