in my arts practice i’ve been interested in ongoing (and parallel) documentation of works i’m making. this has been a big part of my work with skellis and jacob lehrer. and blogs have been the main format for maintaining the document.
i find them fascinating records to look back on - but also vitally useful in terms of the creative process.
in medicine documentation is also used ubiquitously. the document then traverses and conveys the condition, pathway, management, treatment and outcome of a patient (amongst other things). clinical notes in hospitals are ideally a way to allow various clinicians to communicate with each other about the patient in question. they’re also a legal document that keeps track of who did what and what was done when and what was discussed and consented to and so on and so forth.
it really is a vital part of health care. and not always done particularly well.
i had an experience recently that reminded me of the importance of documenting everything that happens. i was on rotation in the ED and had seen a few interesting patients (one with ?SAH / ?Bell’s Palsy and another with Tuberous Sclerosis) when a consultant i hadn’t met asked me if i would like to see a patient. he then sent me to see a young child with vomiting and diarrhoea to take a history and do an examination.
as i approached the child and mother i was already thinking about the recent outbreak of rotavirus at the hospital. not something i wanted to get and take home to a 7 week old baby. so i determined to take the history and leave the examination to the consultant.
this all went well and i wrote up my notes then went to speak to the consultant. i presented the case and then explained why i hadn’t done an examination. he said that was fine and that he understood and that he would take care of it. i went back and spoke with the nurse attending this child and explained that the consultant would be coming to examine the patient.
i then signed the history i had taken and left for lunch and to do some study.
when i returned to the ward a few people told me that there had been some problems with the patient - that no-one had seen the child for 2 hours after i saw him (he was not a well child - dehydrated and malnourished). and, despite me telling the nurse what was happening and having a verbal confirmation from the consultant that he would “take care of it”, that had not happened. in fact, nothing at all had happened.
so the new consultant on call spoke with me to find out what had happened. it looked like it was going to be some reprimands, but i felt i had done enough and explained what had happened. but, now on thinking about documentation, i hadn’t done enough.
while the final responsibility for the patient remained with the consulting doctor, it was also my responsibility to make sure anyone who would become involved with the patient would know what was going on. i should have documented that i’d spoken with that particular consultant and noted the discussion. that way, if the patient was missed in hand over - or any other clinician coming into the ward saw the patient they’d know what had happened so far.
ultimately, in this case, nothing terrible happened - but it was a good reminder of the importance of documentation, both as a way to address accountability and as a means of best managing the health care of the patient.
