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28 March 2008

Decoding Progress Notes

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I just arrived home from my graveyard shift. It was not that difficult for me to review a certain patient's file but what I had a while ago was a little time consuming. I could not figure out what medication did the physician wrote in his progress notes. And he used abbreviations that I am not so familiar with, although it was internationally recognized terms. The research took my time to finished my job within my shift so I had extended some time.

Why do some doctors do not write their orders legibly? When I was working in the hospital, It was one of my problems, decoding what they really want to do with their patients! (lol) Especially now that I am facing with hundreds of doctors order and progress notes to decipher, my world became more complicated! Even how I turn my head side by side, zooming the pdf up to 200 percent still some handwritten files are unreadable. But it is part of my job, not only as a medical historian but as a nurse.

Whether we like it or not, decoding doctor's order is part of our daily hurdle. Sometimes it is annoying but most of the time it is challenging.

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