As silly as this may sound, one of the most exciting things I’ve done on the wards is writing in patient charts. It gives me a satisfying sense of responsibility and makes me feel like a trusted member of the team. But that could just be me!
10 things I’ve learned regarding patient charts:
- The whole world would be happier if charts were electronic.
- Everyone on a multidisciplinary team has better handwriting than doctors – MUCH better.
- Sometimes, doctors really do have nice penmanship and you are so so grateful.
- You spend a lot of time looking for charts because another person on the team is using it. Refer to #1.
- You need to put a patient sticker on every piece of paper in their chart. Things fall out of plastic sleeves and papers get ripped all the time. Refer to #1.
- You are happy to see that the file you’re holding is “Volume 1” and not “Volume 7” because that means: the patient has not had lengthy hospital stays and you don’t have a ton of catch up reading to do.
- Forget white coats, charts are the dirtiest things around. They get carted around the hospital everywhere the patient goes, are constantly manhandled by innumerable hands, and never get cleaned… ever. Refer again to #1.
- It is always better to be more detailed than brief in your charting.
- Describing patients as “pleasantly confused” is a lot more common than you think, especially in geriatric wards – thanks to dementia. It sure took me a second the first time I read that description in a patient file.
- Unlike my seniors, I am not even close to mastering the art of reading through an entire patient chart in less than 5 minutes, while retaining everything I read. Got a loooong way to go.