Monday, October 4, 2010

why is accurate medical charting so important?

Because a baby who was promised a Sunday discharge will NOT be discharged if someone passes on a bad piece of information or puts it in the WRONG CHART. We are still in the hospital at 9 AM  Monday. The Resident came in at 6 AM and  asked how Daniel was this morning (sound asleep thank you until you came in and threw his covers back and poked his tummy  without speaking to him and you scared him silly) and I  replied that he was fine, just like he had been on Saturday and all day Sunday:no fever, no vomiting, lots of wet diapers, tolerating feedings well, no need of pain medicine....what I had said Saturday night and Sunday morning. I asked why we had been told yesterday morning we would be going home and then the orders were not written and discharge denied  last night. He said that they had to keep an eye on Daniel because he had diarrhea yesterday."NO he did not have any diarrhea or any other form of  b m .."  No one asked us all day long about this so it makes me think it is not in Daniel's actual chart, but that this bad info was passed or mistakenly noted by the Surgical Residents themselves when making rounds.  As I was trying to console Daniel from the Resident's  assessment skills, one of the Residents made the comment,
boy he is really whiney fussy isn't he?" (DEEP BREATH Mamma, deep breath!)
   I slowly explained that while  I understood that they could not stop and explain everything to every patient before they did an assessment, in Daniel's case, he is blind, has severe spastic cerebral palsy, is very cold sensitive, and very easily startled. By not speaking to him before exposing his body to cold and touching him, it would most likely take me 20 minutes to calm him down. etc, etc..... (It did.) I hope that by not going ballistic or rude on this young group of future physicians, but gently teaching about PATIENT as PERSON that they will remember Daniel and take a bit of time in the future  to approach other patients as people before they approach the object of their rotation in med school.
Nurse pause.

AAhhhhhhhhhhhhhhhhhhhhhh! We are discharged! No more leads, no IV, no pulse oxymitor , just a calmed dowwn contented-looking baby in my arms as I type one-handed! Charlie is on his way!

2 comments:

Mom to 9 Blessings! said...

YEAH GOD!

Love you xoxox

Jill
ENJOY GOING HOME MOMMA and DANIEL!

"Are These Kids All Yours?" said...

GLAD you are HOME!!! Glad you took a deep breath....hard situations sometimes- bring out the best and worst in us.....