Thursday, October 27, 2005


It's all about documentation. Everything I do during the day that has anything remotely to do with patient care has to be documented. This is helpful in three ways:

1. Somebody else that comes along after me can read my notes, understand my plan of care for the patient, and continue the treatment. This way the patient is insured a continuity of care.

2. I may forget what I've done for this patient in the past, and by reviewing my notes, I can refresh my memory and continue to provide optimal care.

3. In case of a lawsuit, I can count on my written notes as proof of any testimony I give.

I write so much, that I routinely use up an ink pen at a rate of about one a month. Prior to med school, I've rarely experienced the phenomenon of having a pen run out of ink.

So to make our lives easier, we dictate some of our notes as well. Not only is it easier to read a type written note, it's faster for me to dictate than write.

I've noticed that some people, as they dictate, separate out their sentences by stating "period", "comma", "new paragraph", and other random things. Example: "I cut the vessel in half, period. However comma I notice no bleeding period. New paragraph. I then freaked out period." I guess this is done to make it slightly easier on the transcriptionist.

I, on the other hand, assume that the transcriptionist has at least a rudimentary idea of how sentences are structured and I just ramble on. No mention of periods, commas, colons, semi-colons, new lines, or any other little punctuational items. The past four years I've never had a problem with this. When I do happen to read over my dictations, I notice that the transcriptionist has done a terrific job of separating out my ramblings into a well formatted document.

However, I happened to look at a note I dictated recently to see that the transcriptionist typed out my dictation as one long sentence. A long sentence that ran on for 3 pages describing how I took a gallbladder out of someone. No commas, periods, or dashes, or punctuation marks of any sort. The first letter was capitalized, there was a period placed at the very end, and... that was it. Three pages of words strung along, looking like someone with a psychiatric difficulty typed it out. Very much remniscent of The Shining.

The hurricane must have had something to do with this.