Dr. Quaid was a phenomenal cardiologist, now retired and indulging in another talent, art. He has a fondness for John Deere Tractors, a very wry sense of humour and a quiet demeanor. I haven’t seen him in ages but he used to run and enjoy outdoor adventures and I think he was secretly proud when his daughter was Mickey Mouse at Disney World one summer. If you live in Baton Rouge, you can see a drawing he did of the graduating class of Episcopal High at Raising Cane’s on South Sherwood.
So, I have an enormous amount of respect for Dr. Quaid and I can honestly say that I like the man. He is my second favorite cardiologist after Dr. Wall. Having said that, please take notice that when I described all of his wonderful characteristics, never once did the words, ‘warm’ or ‘fuzzy’ find their way onto your screen. He is not one of those men that people call a Big Teddy Bear nor is he the go-to guy for small talk or casual conversation.
You need to know this about Dr. Quaid to understand the kind of day I had when I was working in CCU a few years ago. A patient who happened to be a relative of one of Dr. Quaid’s partners had an urgent need for a pacemaker. Dr. Quaid drew the short straw and had to install the unit and I was the only nurse with an empty bed.
He was not happy and I was not happy and the entire unit was not real happy but off we went to conquer another case of nagging bradycardia.
With marginal cooperation from the patient, Dr. Quaid began injecting the area with Lidocaine and began in earnest to float the weapon of dysrhythmia destruction down some large vessel towards the heart – I believe they call it a subclavian but then again, I wasn’t the one steering. As he was doing so, the patient‘expressed some discomfort’ (screamed at Dr. Quaid to stop) and a decision was made to give him more lidocaine.
It was probably one of those cost reducing measures that resulted in the Central Line kit having only syringe in it. That one, lonely syringe had long been knocked on the floor but I had another syringe Dr. Quaid could use if he did not touch the cap. I told him this. “Do NOT touch the cap,” I said loudly and clearly.
He touched the cap which meant I had to tell Dr. Cheerful that he was contaminated. Worse, there were no size 8 gloves in the cart and he wouldn’t even try on the 7.5’s.
So I went to fetch another pair of gloves out of the supply room and somehow caught the corner of the sterile field, knocked the clipboard off the sink causing papers to fly everywhere and tripped and fell through the curtain that was affording the patient (but not me) a small measure of dignity. I got Dr. HugeHands his gloves and then stopped for a brief second to emotionally prepare for my imminent death or worse; that moment when I wished I had assumed room temperature but didn’t.
So, I can’t say I stepped lightly back into the room where Dr. Quaid was putting my mess in order. I handed him the gloves and waited for that first caustic word but it never came. Silence. Utterly loud, screaming silence.
He quietly returned to his task of electrical wiring but I knew he was unhappy. I’m intuitive that way. I pretended not to notice and watched the monitor to see when the pacer wire found its way to its final destination.
The silence grew louder until I couldn’t stand it and I blurted out that I had endured 14 years of ballet lessons in three countries because my Mom thought it would make me more graceful but she was wrong. I did not tell him about the ballroom dancing taught by nuns, the tennis partners who refuse to play with me unless an ambulance is on standby or the fact that I have been voted most like to die of a closed head injury in yoga during Savasana. Still not a word from Dr. Quaid.
After three hours or maybe it was only three endlessly long minutes, he stopped in the middle of a tying a suture, made direct and intimidating eye contact with me and said quite simply, “I hate to imagine what your life would have been like without those dance lessons.”
There is a reason why I am telling you this ridiculously long and utterly humiliating account of an incident that happened long ago.
Keep in mind that on more than one occasion, seizure precautions have been implemented as I attempted to dance when I tell you that many of you cannot write for beans.
Remember that I have been described as an arthritic swan by ballet teachers when I point out that some of you cannot string together a grammatically correct sentence to save your life. Its downright sad to see some of you go through your entire vocabulary in one clinical visit note.
That I have twerked by accident during a Waltz should you make you feel better about visit notes that could be used as a poster for an Adult Literacy campaign were it not for the HIPAA Privacy Rule.
The fact is…. some of you simply do not write well and that’s okay. Apparently, I do not dance very well. Much to the dismay of others – a whole lot of others – it doesn’t stop me from trying.
If I hurt your feelings and you are ready to quit, don’t. If you think your computer documentation will solve your problems, get over it. If you have lived more than three decades and find yourself correcting more than half of your visit notes after review, give up on trying to be a literary presence. All you really need to do is accurately convey your thoughts on paper and I am going to teach you how. Remember, Medicare does not pay for grammar and spelling. There are no Pulitzer prizes for visit note narratives.
Instead of trying harder, working more, adding more drivil to your notes, simply document the following on each and every visit:
- A short description of the patient and what they were doing when you got to the home.
- A complete assessment including weights. Note: in other health care environments, patients with aortic stenosis have very loud heart murmurs and patients with COPD wheeze. In other words, document your findings – don’t just check the same old boxes you normally check.
- A review of all medications against orders. Document any discrepancies.
- Problems assessed on the visit and any events reported since the last visit.
- What you did about the problems.
Patient at table making holiday plans with f’ly member upon arrival. Med planner reviewed and noted all medications present. Pill bottles examined and called MD for refills for Metoprolol. MD office nurse stated meds would be called to Walgreens. Pt has loud murmur which has been there since admit. MD verified that pt always has murmur on admission. Diabetic foot care done by patient while SN watched. Pt performed foot care with just a little coaching from nurse. Pts daughter present during visit and she agreed to pick up medications. Will follow up.
Then write yourself an email or put a note to follow up on your calendar. Call the daughter who picked up the meds to verify they are in the home and write a case conference that says: ‘Daughter said she picked up meds from Walgreens. See visit note of 09/13.’
Compare that to:
Pt was instructed on the significance of attempting to remember if he took medications before taking other meds.
I read that in a chart of a patient with Alzheimer’s Disease. Medicare paid for a nurse to instruct a patient with Alzheimer’s on the significance of attempting to remember if he took medications before taking other meds. And you wonder why I am so brutal in my assessment of your documentation.
The truth is that I know you guys. You work hard, keep patients out of the hospital, make them well and happy and you deserve to be paid – not arrested. I’ve heard some of the documentation classes. I’ve read the examples. Please don’t bore me with those cold, clinical assessments that tell me nothing about the person you are visiting.
Go practice. Keep it simple.