Showing posts with label at work. Show all posts
Showing posts with label at work. Show all posts
15 April 2008
28 March 2008
Decoding Progress Notes
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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