One Dozen Things
About the One Dozen Things | The Doctor-Patient Relationship | The Role of the Patient's Family | Confidentiality | The Health Care Team | America is a Litigious Society | Document, Document, Document! | Who Pays the Bills? | Gender Issues and Discrimination | Safety and Errors | Informed Consent | U.S. Graduate Medical Education | Above All, Professionalism
Document, Document, Document!
Discussion Questions
1. What deficiency in the resident’s patient notes raises the attending’s concern?
2. Why is the sequence of the entry of information critical in this case?
3. Should the missing information be entered into the medical record now? If so, how should that be done?
4. If there had been an adverse event with respect to the spinal tap, how might the resident’s and the hospital’s liability be affected by the timing of the entry?
5. How effective was the attending in educating the resident about the importance of timely and accurate documentation? How might he have been more effective?
6. What does the resident’s final response suggest?
7. How should entry errors in medical records be corrected?
