Friday, April 07, 2006

Chart Wars

Got a nagging cough?

Have you tried.....Heroin?

Did you know that aspirin was the substitute for salicylates?

Piperazine: the antiarthritic? It's a worm medicine!

Hemicranin? Sounds like a neurosurgical procedure.

Somatose? It's the name of an Australian rock band (I'm serious, check out Google!)

You could send for samples! Yes, I'd like a sample of heroin, please. Would it be possible to have two? Actually, I 'll need a case if you can possibly oblige. Nasty cough, this is!


I have a reputation.

I am a chart hoarder.

I hoard charts.

99.9% of the time, if a doctor needs a chart, I have it.

The other 0.1% of the time, my elbow is on it, a chart of mine is sitting on it, my eyes are gazing upon it or I have just moved it to the side to make room for my charts.

It doesn't matter. Doesn't even have to be my patient.

The docs always know I have the chart.


My philosophy of ER nursing is: Patient Flow = do now, chart later.

So, if the unit is crazy, I will chart medications given and IV start times when it is done. I will then write notes on scrap paper, pieces of tissue boxes or paper towels (hey, at least I'm honest) that I attach to the chart via paper clip.

These charts go into "my office". Then, when things settle down, I will take the various notes and create a consise, coherent narrative of the patient's ER visit.

This drives some of the doctors I work with nuts. Really nuts.


I don't mean to do it. Really I don't.

It's just that our doctors are dictaters.

(No, I did not say "dictator" as in Fidel Castro. I wonder how many search engines will send people here looking for his hairdo.)

Our doctors dictate all their charts. The amount of nuttiness I produce in any particular physician depends on their style of dictating.

There are four styles of dictation:
  • Those who dictate before they write the discharge instructions. It slows patient flow a little, but when they are done the chart is all mine.
  • Those who dictate as soon as the patient is discharged. This causes only a short period of distress as they usually find the chart in "my office" within five minutes and when they are done, the chart is all mine.
  • Those who dictate after they have a moderate amount of charts piled up and then realize they have seen more patients than their pile would suggest. This causes a moderate amount of mental distress for the doctor, which is easily resolved when they pull rank, come over and raid "my office" even as I am trying to complete my precise charting ministrations.
  • Those who dictate when the mood hits and don't care when the chart hits their pile. Very mellow, these guys. Take your time, just let them know where "my office" is and if they want the chart they'll go get it. This is usually a night shift style. God Bless the night shift.
And then there is the situation that makes even the most jaded, experienced nurse tremble with trepidation:


Hell hath no fury like that of an ER doctor, who after breathing a deep sigh of relief that their day is done, is handed five more charts......from "my office".

Yes, ladies and gentlemen, I lived to tell the tale.

It's a mistake that you make only once.

Trust me.


The War for the Charts reaches its apex when a patient is being admitted, for it is at this time that both the nurse and the physician need the entire chart at the same time.

The doc has to dictate and write holding orders and I need to write report and fill out a bazillion other pieces of paper, using the chart for reference.

Since the patient can't go upstairs until the doctor is finished and holding orders are written, they get the chart first.

The goal of both the doc and the nurse mesh at this time because we need to get the patient out before the admitting doctor, consultant or hospitalist arrives on the unit.


If we cannot get the patient up before the next physician reaches the ER, all bets are off.

They get the chart. The entire chart. For the entire time they are there.

And while I am always happy to give up a chair to a doctor who needs to write (I have a million other things to do as it is), they will s-p-r-e-a-d out the entire chart over the entire desk and take up all the space available, which usually encompasses "my office".

I can't even access my nurse's notes.

Geeze. I sound like a toddler who can't get to their crayons.


No matter who "wins" the War of the Charts, being the flexible,competent professional I am, I have learned to adjust my charting style to whichever physician is on at the time.

But it never fails.

Ten times a shift, I will still hear that eternal question:

"Kim, how many of my charts are you hoarding?"


And now for something completely different.

I have succumbed to the urge to make a South Park character of myself.

The halo is because I am an angel of mercy, doncha know.

In my right hand is a bottle of Magnesium Citrate for all the constipated patients I have to see every shift.

The iPod is there because it's cool.

In my other hand is holding a cup of oral contrast for an abdominal CT that will form a head like a glass of beer if you don't add the water at an angle.

See what you learn on the job?

South Park Characters


At 4/10/2006 02:11:00 AM, Blogger Barbados Butterfly said...

I love South Park Kim! Totally gorgeous.

At 4/10/2006 05:09:00 AM, Anonymous Moof said...

Kim, I love reading about you and your chart adventures! This has given me an even better picture of you! :o)

At 4/10/2006 08:43:00 AM, Blogger Charity Doc said...

Gawd, I love your posts! Sure the foamy stuff in the mug is CT oral contrasts. Wink, Wink. If they don't buy that it is, you can always tell them it's Mag Citrate!

As to your observations on the never ending Chart War, so so true! This is what I do. Make a quick copy of the triage sheet and ask the nurse/secretary to give me copies of the labs. That's all I really need to complete my dictation. Cuts down on the chart hoggin'.

I belong to the He Man T-sheet Haters of America Club. Proud card carrying founding member.

At 4/10/2006 08:48:00 AM, Blogger Jo said...

I've seen those SP characters everywhere and didn't know where to get one, Thanks!

I'm constantly taking the nurses notes and MAR out of the chart so they don't go missing when an Intern swipes the chart. It's worse on a residency teaching floor when you have a "team" of doctors; interns,residents, and attendings fighting with the nurses and aides over dibs on charts. It's a wonder anyone gets to see it.

At 4/10/2006 02:01:00 PM, Blogger Flea said...

And when you write in your charts, Kim, repeat the following mantra to yourself:

"I am cutting rope with which to hang myself. I am cutting rope with which to hang myself..."

This will improve your risk-managment skills enormously.



At 4/10/2006 04:58:00 PM, Blogger mary said...

I thought they put paper towel dispensers in the rooms to hold the nurse's note paper.

Didn't they????


Course, I remember the days when you wrote on the legs of your scrubs, but that was before you had to buy your own...

At 4/10/2006 06:13:00 PM, Blogger ChiaLing81 said...

At least when an RN has the chart I know where to go looking for it - when I can't find a patient's chart so I can record my nurse aide stuff, I suspect that a group of new MDs has sneaked off with the chart for the whole morning....

BTW, I love your South Park character. Gorgeous!! CT oral contrasts, my bum. ;)

At 4/11/2006 10:13:00 AM, Blogger TBTAM said...

Wat you need is an online medical record. Then anyone can have the chart whenever they want, and no one can hoard or lose them.

Love the SOuth Park character.


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