One Dozen Things
Document, Document, Document!
Scenario Script
A resident is sitting at a desk surrounded by charts. Her attending physician walks over.
Attending Physician: Okay, let’s review Mr. Kahlil’s chart. [He reaches into pile, extracts one folder, and leafs through it]
Resident: He is being worked up for a seizure disorder.
Attending Physician: He had a CT and a spinal tap?
Resident: Yeah, I did it right after he came in.
Attending Physician: OK, here’s the CT report… nothing there… and the spinal tap results [leafing through the chart] also are of no help. You did write a procedure note for the spinal tap, didn’t you?
Resident: Yes, here it is [flips through charts to find it].
Attending Physician: [Takes a few moments to read the chart] You did the tap after you saw the CT results, right?
Resident: Of course…
Attending Physician: But you didn’t note it in the chart.
Resident: What’s the difference?
Attending Physician: Potentially, if he had elevated intracranial pressure, he could have herniated. That’s why you see the CT first…
Resident: I don’t see why it’s such a big deal. I didn’t write it but I did it. I saw the CT report before I did the tap.
