It’s amazing how much damage documentation can do, but it’s true.
Chart lore is another of my favorite (least favorite?) issues with documentation. Documentation is so often copy-pasted, or simply assumed to be ground truth, that inconsistencies or inaccuracies can be difficult, if not impossible, to correct. I remember having a patient with ‘dementia’ as noted on his chart, but when conversing with the patient, you’d think his mind was totally intact. I asked him about this, knowing that many patients with dementia will not have awareness of ther illness. He had no idea what I was talking about. I talked with several members of his family and they all agreed, the patient didn’t have dementia. The chart was wrong.
But this is a diagnosis with huge implications - how could all of the physicians caring for him have gotten this so wrong?! I could never find where the falsehood started, but it was simply carried forward over years and no one had either noticed or known how to fix it.
The family asked me to remove it from the chart. How do you do that though? It was in hundreds of notes over years of this patient’s records. All I could do was make a single note in my note, ‘the patient doesn’t have dementia’ but I doubt that really fixed it. This information couldn’t be made persistent so that everyone could see it when looking at the information related to ‘dementia’. At River Records we understand this and have a solution we think you’ll like.
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