Today’s entry is a brief one, for I have done it again: I went off to work and left the computer cord at home. In a few hours, there will be no more ‘juice’ in my laptop. It will be cold as a mackerel.
I write my progress notes as I talk to my patients. Happily I am a whiz at typing. This is one of the few areas where I can multi-task viz. type and listen. Provided I remember to make eye contact, patients don’t seem to mind it – or so I think. I used to work with a physician whose patients constantly complained he never made eye contact with them while he used his laptop. Hopefully I am not that bad.
A typed, detailed, easy to read progress note may be extra work while composing it, but it is vastly superior to handwritten rubbish for later on. I am proud of my notes. I continually get transferred records from colleagues, whose notes are essentially worthless. Besides being usually illegible, they do not tell me ‘why’ things were done, but only the minimal what was done. Bad documentation is an amazement to me, especially in this day and age.
I write my notes knowing medical records are about as private as Facebook or blogging – everyone is going to read them: the patient, other medical providers, insurance companies, attorneys, etc. I have to write tactfully as well as truthfully. Sometimes more delicate topics have to documented with discretion. If “Joe Smith” is in a workmen’s compensation everyone will soon be reading about his erectile dysfunction and his affair with the company’s secretary.
But not today; the laptop battery is near its demise. I will write today’s progress notes by long hand, and then type or dictate them throughout the week.
On the positive note, I will save time today, for I will not be able to go on-line to read e-mails, check the news, etc. Have you ever noticed when we are away from time – saving devices there is actually more time on our hands?