Do you document your verbal interactions?

Recently, I had a shift change, during which I received a doctor’s script saying:

“Patient should’ve been on Diovan HCT not Diovan”

Who wrote this? Could be anyone.
When did this happen? Nobody knows.
What was the route of interaction? I don’t know.

Concerns:

The patient might have elevated blood pressure or other complications. We have to make sure to follow up.

If you didn’t write it, then it didn’t happen. But, make sure to write it right.

Not only it is important to write down every communication, but also to do it in the right way.

Who documents this type of information?

Only eligible or delegated professionals in your healthcare setting, within their scope of practice.

What is it that I document?

Everything that’s relevant

Examples:

• The patient can not swallow tablets and prefers liquid, and if not available, then capsules

• Doctor (so and so) stopped patient’s clopidogrel but to continue daily aspirin because ……………………………………………………………………………

• As per colleague (name/initials) “patient’s sister -who is consented- called in and wanted medications to be blister-packed”.

And many other verbal types of interactions you think might be relevant or useful for workflow and patient care. Use your discretion when documenting, for example, a general note that is ongoing and might affect patient care, versus a specific note particular to a certain situation, and may not be needed longterm.

You may also write down the route of interaction made, if plausible.

Part of best practices of documentation is keeping it up to date. When relevant and possible.

Documentation also involves patients’ profiles. Train your staff to update addresses, and phone numbers of patients’ profiles. Why this is so crucial?

Reaching out to patients in a timely manner when having a related emergency was due to an updated profile with the correct phone number and address. Dispensing errors were corrected because the patient was contacted right away. When important Lab results are to be sent out, they need to be sent out to the most recent correct address. This is how updated patient information is very important.

Another good practice is to write/type it down right away, or as soon as possible. Don’t postpone it, because, during the rush, you might miss it, or miss important parts of it. A habit that needs to be practiced.

Finish up with your name/initials, and/or signature, date, and time.

Where do I document? Where do I store the document?

1- Original document; where clarification or other inquiry has been revolving around

2- Computer; This has two routes:

a. Paperless, typed in.

Depending on the type of software you are using and different windows, and -within windows- available in that software.

Make it stand out and clear for a quick check by you or the next professional who might need it. The best place would be the main page of the patient profile, highly accessible for a quick check. In some software systems, you could also make the note pop up, if it is highly important. Use your discretion when documenting issues inside hidden windows within the profile.

b. Scanned copy of the original document with handwritten documentation included.

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Other sorts of documentations:

• Allergies and other medical conditions. If you find these sections blank, take a step forward, and update that info in the profile when you have a patient encounter.
• Complete med list including OTC medications, vitamins, herbals, and supplements. These drugs are usually underestimated for their drug-disease and drug-drug, and drug-lab interactions. In addition to reviewing their safety and need to continue by the healthcare provider.

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