“If you didn’t document it, it didn’t happen.” That’s fine but I can’t turn my note into a second by second diary of my shift. I do a lot of stuff and it would take as long to document it as doing it. Where do you draw the line?
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Replying to @efunkEM
A lot of people are adding to the medical record (RNs, Pharm, RT, etc). Chances are 99% of interventions are documented there somewhere
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Replying to @concernecus @efunkEM
How I see it is that when you place your MD orders, that’s documentation. When RN, Pharm, RT, PT implement your orders, that’s documentation. We use Epic and if we utilize the awesome features it would help make documentation easier.
3 replies 0 retweets 2 likes
the problem is from a legal perspective you are also expected to document your thought process. that you considered a PE and dissection but did “nothing”.
9:07 AM - 17 May 2018
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