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You have asked the 50 million dollar
question and I would love for someone to have the answer. I feel your
frustration. I don't think you are alone in the documentation issue.
Many of my peers have expressed the same frustration in getting physician and
nurses alike to improve on documentation. I received a worksheet from
someone else on the listserv awhile ago, which helps with burn
documentation. I have modified it a little and have just instituted it
here at my hospital. Now I am just hoping it will be used.
One of our problems here is that we are making a switch from hand written
documentation to computer generated documentation. The switch is not
complete, and will take several years, so documentation is split between the two
and is horrible. I have attached the forms for you. I hope you can
get some use or ideas from it. Good luck and just keep trying.
Debbie
Haliscak
Hi
all,
I need
help. I have an ongoing issue with physician PI. We are a
level III center. The issue is I have 19 - 22 ED physicians in their group. I
have a problem - for example not documenting Parkland's formla on a burn
patient. I presented this same issue last year to 4 different ED Physicians at
different times through out the year. I also presented it at Trauma Committee,
ED Section meeting, GVT section meeting and then I followed up by printing the
CE course and test from the ABA web site "The challenges of children: the
first 48 hours" and put a copy in everyone's (nurse and physician's box) in
the ED. For nursing it was a mandatory test and I got back about 1/4 of the
them.
Well this
past week we had the same issue - different MD. HOW DO I GET THE MESSAGE
ACROSS TO ALL OF THEM AT ONCE? I don't want to make this same mistake 19 - 22
times before they all get it. With physician PI it is behind closed doors, and
a single physician is accountable / or not - how can I make them all get it so
we stop this stupid trend?
Thanks
Lisa
McLaughlin, RN
St. Vincent
Hospital
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