Hi everyone,
I hate the axiom "if it's not documented, it didn't happen." The expression superficially resembles philosophical quandaries about falling trees and sounds they may or may not make when no one's around to listen. The question probes the nature of sound and the transformation of physical phenomena (sound waves) into experience (hearing).
Questions about undocumented cross-coverage vex me too, although the concerns are far more practical. Missing documentation can mislead day teams into thinking nights were quiet when they weren't, or sow confusion about the way events unfolded. Who started the oxygen? Why was Lasix ordered? What did they think was wrong? The nurse wrote "MD notified," but what happened next? The overnight team's home now; too bad they didn't leave a note.
Of course missing documentation doesn't mean nothing happened, but because we haven't set clear expectations about note writing, our practice is inconsistent. Which encounters needs notes? What information should we include? Can we improve documentation without over-burdening the night teams?
Missing documentation can mislead day teams into thinking nights were quiet when they weren't, or sow confusion about the way events unfolded.
We tackled these questions at last Friday's Program Director's meeting and agreed to list the encounter types needing documentation and to develop a new, efficient documentation tool. Jackie Hirsh was kind enough to propose the attached policy and a cross-coverage "dot phase," which she developed with Amir Mohareb. Tell us what you think of the proposal and let's plan to pilot a new system over the next couple of weeks. Maybe if we do a better job documenting cross coverage, we can avoid pseudo philosophical debates about what may or may not have happened when we weren't around.
Enjoy your Sunday, everyone,
Mark