If there is one thing I can not stress enough, it is that wherever you are (as in whichever country you work in, not your present location of the bathroom or the grocery store!), whatever you do (whether its emergency medicine or you’re a newly born FY1), whoever you are, always remember: DOCUMENT!
If you do something or say something or let the patient know, or if you don’t do something, or don’t say something or don’t let the patient know, DOCUMENT the conversation or the deed (or the lack thereof) and the pertinent details of the interaction – for your own good. I always try to tell my juniors (and anyone else for that matter!) that always think of your notes as someday standing up in court as a means of defending yourself; at times the ONLY means. Will you remember the 3rd patient on your 57th day of work in your 4th year of training, 3 years ago? Well, you may. But will you remember exact details? Not likely. So think of it this way, whatever you write down, or don’t write down, will always end up saving you. Or screwing you over, whichever way you want to look at it.
If you see a patient who, let’s say has epilepsy or you are working them up for a possible or probable seizure, sometime during this interaction it is your duty to tell them very clearly that they are not allowed to drive. And then also DOCUMENT that in your notes. If this patient then decides to continue driving, and ends up in an accident, it is very likely someone will pick up on the fact that he had a similar episode sometime back, and they will then look at your notes of the interaction. Now suddenly, every word you have written down (and also not written down) becomes significant. If this patient then goes on to say in court that he was not told he could not drive, and your notes do not mention you giving this advice, not only will you have aided him in escaping punishment for his poor judgement and from an unpleasant fine-slash-jail situation, but also it now becomes your fault, your poor judgement under scrutiny, your job at stake, your medical degree in question and your license in danger of being revoked. DOCUMENT!
If you use a chaperone for an intimate examination, DOCUMENT their name clearly in the notes. If you offered a chaperone and the patient declined, DOCUMENT that as well.
Always date and time your notes; always DOCUMENT your name (I prefer using my last name) instead of your signature. At the start of writing anything on a clinical document, look at the time and just put the time and date in right then and there; make it a habit to avoid problems. Any further changes or updates to the plan, document beneath it, with the new time (and the new date if applicable). When continuing to the next page, just remember, this page may at some point become lose and be put back in the wrong order, so always make some mention of the date time and who you are on the new page as well. Granted that sometimes when you are too busy to update notes continuously and in time order, you can go back and document your findings, but always do so by documenting clearly that these notes were written in retrospective. People understand; you’re a doctor. No one’s going to go ‘Right, can you intubate this patient with one hand and write up the information with your other hand? Thanks!’ and if they do, you can punch them and document why. But always document. (Ignore that last part. Do NOT punch them. Please)
You bleeped the cardiology registrar. They haven’t responded. DOCUMENT that. You bleep again 10 minutes later. Someone calls back, and tells you the cardiology registrar is busy because she is passing a critical line into a critical blood vessel in a critical patient (you see what I did there?) and you reassure them that you just wanted some non urgent advice and to ring back when free. DOCUMENT that as well. It’s not just helpful for whoever reads the notes as to why the cardiology consult took so much time, it’s also just common courtesy.
You have just broken the bad news of your 88 year old patient’s new diagnosis of metastases to the liver, unknown primary for which you give them a plan for workup. You offer your help; you offer tissues, water, a hug. You listen to their questions. You offer them to take their time digesting this information, and that you will come back when they are ready and answer any further questions and even repeat anything that they want repeated. You have the ward nurse present with you during this interaction, and the patient granddaughter and granddaughter’s boyfriend (with the patient’s permission) are also present. Your patient says she does not want to proceed with further investigation and treatment, that she has lived a long full life and is quite satisfied. You still offer your support and offer to re-address this at a later point. And any specialty that can come in offer their opinion on this situation. What do you write in the notes? EXACTLY ALL OF THIS INFORMATION. WITH THE DATE. AND THE TIME. AND YOUR NAME. And the granddaughter’s name, and her boyfriend’s if you have remembered to ask him, and the ward nurse’s.
Bottom line: Document every pertinent aspect of patient care; whether it’s your interaction with them, information from investigations, information from colleagues and staff on the ward or care staff from the patient’s nursing home, or even if it is to say that you came in to see the patient but the patient was not in her bed, or that she had gone for a CT scan. Trust me, you do not want to learn the art of documenting the hard way: when you fail to document something and it comes back and haunts you. Not just haunts you, but bites you in the ass. DOCUMENT!