Dear Always Believe,

Thanks so much for your post. Loved the story of your daughter's tonsils. That is such a perfect example in showing the erroneous charting that is flooding our files today.

I was at the hospital today for pre-op. During the anesthesia interview, prior to seeing the anesthesiologist, I was asked a million and one questions about the same things that were asked of me on Wednesday of this week and in the computer. Forget all the redundancy, I just want to know why they type something different than what we say? Why ask us if you are going to type whatever you want to any way?

Don't get me wrong. I understand if they are "translating" the patient's lay terminology into medical jargon.

I was asked today, when I injected a particular drug. I said at 1 PM everyday. Guess what was typed into the computer? Med taken after lunch.

Did I say anything about lunch? NO. I think MY answer was MUCH more accurate and informative than what was typed. After lunch could be anytime. After lunch could vary from one day to another. After lunch may indicate that it was NOT regimented.

My answer was I take it at 1 PM everyday. End of discussion. Everyday at 1 PM. It does not matter if I had lunch or not. Or if I had lunch at 11 AM or at 3 PM. I inject the medicine at 1 PM every day. This is the time my doctor and I have agreed upon and it is to be adhered to strictly. This is also how the medication should be used. The drug company does not say, take whenever you eat lunch. It says take every 24 hours.

And guess what? It is a medicine that is suppose to be administered at the SAME time every day. That is exactly what I do. I use the med at the exact same time every day. At 1 PM every day. Why was that not what was entered?

Another med, an oral med, I said I take after my last meal in the evening. What was typed? Taken at bedtime.

Another oral med is a 24 hour medication that I take at the same time every evening. What was typed? Patient does not take medicine as directed. It is to be taken with meals but patient takes at bedtime.

That was NOT what I said and I KNOW how this med is to be taken. It does NOT need to be taken with meals. My doctor and pharmacist have stated that it does NOT need to be taken with meals. The packaging from the drug company states that it does NOT need to be taken with meals.

However, there is a similar medicine, that IS to be taken with meals but I could not tolerate it many years ago and was changed to the one I take that does NOT necessitate being taken with meals. Maybe the person doing the typing thought I was too stupid to know anything about my meds and they thought they would put the "correct" information into the system. The problem with THAT is the typist is wrong and not aware of some drugs. I believe most people take the drug that I could not tolerate and that was the drug the typist assumed I was taking. They did not READ the name of the drug or did not realize they are not the same thing.

I have NO idea of how many other things were entered differently than my response. The only reason I knew of the ones I mentioned was I saw a print out of that part of the interview.

Totally agree. It does work both ways. What to chart and what not is not always clear cut.

The knife cuts both ways. Too little can be as harmful as too much in some cases. And one never knows ahead of time if that charting will show up in a court of law. (But that is an entirely different subject matter.) In this thread, I am talking about erroneous charting having potential harm on the patient's care. Information missing, incorrect information, misleading information, wrong patient's information, etc.

I always thought of charting as a way to allow the person that may rely upon the chart to provide the best care and have the best depiction of what is going on with the patient. What was done and the outcome. I want a doctor to know me from my chart. I want it to be an accurate reflection of my symptoms, my treatments, etc.

Wow...that's just awful...but not terribly surprising unfortunately.

I still remember the day I was injured at work that caused the RSD. I finished my shift but went to the urgent care center right after and then was ambulanced over to the hospital for more tests. I explained the entire incident several times but also overheard it being related from nurse to dr to nurse to techs, etc. It was like the children's game of telephone...every time someone told the story they changed something until the final story that came back to me what not even close to what happened or what I said happened.

This happens all the time I guess...human nature for someone to try and alter ldescriptions to things they understand or what it would mean if THEY said those words and they change the meaning by changing the words instead of writing down exactly what was said. I often find myself repeating things and clarifying things to make sure they know what I am saying and it still doesn't help sometimes. These errors often lead to trouble when dealing with work comp and I'm sure other insurance companies too. So frustrating...I wish the people taking these notes and writing this stuff down really understood what a negative impact this can have on the patients. I don't think people would be so reckless if they really understood what it does to people...but they just don't think. Too many people just don't think about how their actions affect other people...

Dear catra,

That is EXACTLY what happens much too often. I sure hope that the final story did not have a negative impact upon you in the case of your work injury.

That was such a funny game we played in grammar school. We stood in a line and began with one sentence and "passed it down". And just as you said, by the time it got to the end, there was NO resemblance to the original sentence. We would get such a good laugh.

But in adulthood, it is NOT a game and it is NOT funny. But the end result is the same, a total distortion of what was really stated in the first place.

From many of my posts about the medical profession, I may sound like an old grouch that just can't be satisfied. That really is not how I see the medical profession. I have worked in it and outside of it. I have the utmost respect for the nurses, doctors, technicians, but I also get very frustrated with the system.

I am not sure if it has really gone downhill or was I just not aware before or maybe not impacted by it. Regardless, of when the downfall began, the frustrations get under my skin at times and I find only venting helps ease it.

It is comforting to find that I am not alone in these medical nightmares.

Thanks for your comments.

I have often wondered why we are not given tablets while we are waiting to input information ourselves. When I first went to see the doctor about my burning feet I mentioned everything possible as a cause, including the minor accident to my feet. This was omitted. When I returned in two weeks for X-rays it was again omitted. The orthopedic surgeon I saw next did include it, but it was incorrect. It wasn't until I saw the second orthopedic surgeon that the report is as I stated. I am fortunate that I had witnesses to my accident, because these medical reports IMO would not support my story.

I really hate knowing that other medical professionals have made so many errors. However, I don't want people to think we are all like that. I am not going to say that I have never made a mistake because I know I am not perfect.

With regards to the medications not being charted as exact times this is a problem I have seen in some of the charting programs. In my experience when charting medications there is are drop boxes for different options, for example route or frequency. The only options available may be before meals, after meals, bedtime, etc.

Please don't think I am making excuses for some people charting erroneously because I do know it happens. I just didn't want people to think everything in their chart is wrong. I think more accountability would help tremendously in cutting down on errors.

Hi Nurse Kris,

Thanks for your post. You are so correct. A few "sloppy" people does not mean that everyone is being that way.

I hope I did not offend anyone in the medical field. That was certainly not my intent. I know and have worked with many that are exceptional. Not just good and accurate but exceptional.

I understand that sometimes with the medical software that is in use, some programs do not allow anything other than their pull down menus. I do not know the software vendor or the design of the program, but I DO know that if she was able to type in all the inaccurate stuff, she was NOT limited to pull downs.

Speaking of those pull down menus,..... that is another bone of contention with me. If the accurate information does not fall into an item on the pull down menu, the personnel are "forced" into making a choice of something and that something is NOT accurate, but they have no alternative. Each year, my PCP, has a preliminary patient assessment, designed by a company, (not him) for patient's to complete before their annual review. It covers a wide range of areas and each has specific choices. I have come to truly resent this format since there are many questions that do NOT have an option that depicts my situation OR, to answer with the best choice available, without providing further explanation is very misleading. The first year he enacted this preliminary questionnaire online for patients to complete before coming in, he said that I had the lowest score of any of his patients. Yes, how you respond to the various questions are calculated and an overall score is obtained. After 3 years, I am STILL the lowest score of all his patients and significantly lower.

The areas where my scores pull down my overall so much, are areas that are not pertinent to my health at all. Those areas where NOT applicable is not a choice. I get scored on things that do not exist in my health care.

There are so many different programs in use in the medical arena now and each one is different from the other. As a patient, I now have access to some of my records, from some of my physician's offices and from other medical facilities and each one that I personally have had access to, has been a different vendor. No two docs are using the same vendor for their patient portals, or their own access.

What a run on sentence,.... must be too late at night for my brain to work.

I would love to know how many "other" areas during my pre-op interview had "interpretations", rather than my responses, but I don't have access to that information.

I called one of the nurses I used to work with this afternoon and asked what they would enter into the computer if a patient said they take a med at 1 PM. I was told they would type 1 PM. I said, I was just checking to see if my thinking was off. My nurse friend went on the tell me most of what I stated in the post I made. That to chart 1 PM was not only much more accurate, but also much more informative, leaving little room for assumptions or interpretation.

Guess I am not the crazy one after all. Or, if I am, then my friend is in the same boat.

The title of this thread, Boxed in by over regulation, really hits home with me. I guess it is obvious that I have some issues with the "electronic" medical record and all the regulations now in the medical system in the USA.

I wasn't offended at all! These stupid programs can be extremely frustrating to work with. Sometimes there is a box for "other" you can check and type in what you need. However we are also told to only use that option if it is really necessary and we should try and limit how often we use it. If what we need isn't there I am not going to try and change what the patient says to make it fit into the options available!

I really have a love/hate relationship with electronic charting! I would love for a company to use nurse's input when designing a new software. I say nurse because I think we chart more than some of the other healthcare workers. People aren't like machines, everyone is a little different and we need to be able to allow for that.

I feel like a lot of it comes down to the pressure placed by administration to see as many patients as possible . They are so focused on making a profit that they forget they are in the business of treating people. My PM was new to the company (a big healthcare company with multiple hospitals) when I first started seeing him and I loved how he took the time to explain everything to me. Now they want him to see more patients in the same amount of time. I have talked to him about this and I know he is really frustrated but there isn't much he can do. Luckily he doesn't ask to see me in the office very often and we communicate via My Chart. Side note I really love My Chart because I can see my test results, schedule appointments and send messages to my doctors.

I guess I rambled on again! I just wonder how many mistakes are made because we are forced to rush through assessments and are forced to squeeze everything into these little constricted boxes. However I also believe in accountability for one's actions. Hopefully by bringing attention to these mistakes it can help prevent future errors from being made.

Dear Nurse Kris,

I have been seeing my pain mgt. doc for several years. He was in private practice and his own boss. LOVED everything about him and his practice.

At the end of last year, his practice was moved to the hospital and he is now technically under THEIR thumb, no longer his own boss and calling his own shots. I have only seen him once since the move but it sure was different. HE was the same but they are tying his hands unbelievably.

He still fights for what is BEST for his patients and is not allowing the hospital to interfere with his treatment of patients to the extent he can. He negotiated a deal with the hospital to bring his entire staff WITH him. That was great because he has a GREAT staff. His nurses are the BEST you will find. When I saw him for my nerve block in November, it was such a relief to have the nurses I have come to know and like so much with him.

Time will tell how much he is forced to adapt to the hospital "rules and regs" that create an interference between doc and patient. I know that some things will be out of his control and he will lose some of the flexibility he had in his private practice.

NO ONE, is happy about the change but times are tough for docs in private practice today. My doc, his staff, and the patients wish he had been able to keep his practice the way we have known it for so many years.

I fear that private practices will soon be fading into oblivion. Soon all medical care will be institutionalized and I fear that.

There are pros and cons to BIG medical institutions but I happen to prefer docs in private practice. To avoid getting more lengthy than I already have, I will save my reasons for now.

Hi, the reason for buying scripts in mexico ate i dont have to drive 5 hr for them and pay $500 for 15 min. Also these drs just repeat what the last snotty one said including stuipd diagnosis. The VA stsryed this crap and the rumor mill i was a faker and money gribber tainted every visit. Then i fated to day o was going to sur their fannies brcause they did interfere with self pay appointments. Then dr still dishnosing me as self disgnosing 4 years aftet spontaneous rsd sptead diagnosis. The funny part is the VA gave me my first infusions but not without hell to pay. Then the same dr said i pulled mu gown dow over my brrast dirong a female exam. Then o had a flare up and 5 hr away pm wouldnt return calls. Went to Er and they dumped me calling me s drig seeket. So thats why of tather niy my klonopon in mexico. Het a urats worth, no slander, no shrinks, one time deal. I also got ketamine from mexican dr when i showed him is scripts and history. No hassle execpt i had to get it from a vet. Why would i cpntinue to traumatize myself with this crap all pver my records. Ill never fix it.