Doctors are notorious for writing illegible notes in the charts. Sometimes you have to wonder if they even bother proofreading their chicken scratches. Take this note I saw. While clearly legible, it raises the question whether the doctor or patient is the one that is altered. Under the subjective examination, the physician described the patient as being both "alert" and "confused". Hmmm. Now I'm confused. Or maybe I'm alert and the doctor is confused. Or maybe the patient is alert to the fact that he is confused. A conundrum indeed.
I think I would be guilty of the same offence. I would argue you can be alert and confused. eg someone with dementia is alert but confused. Personally when clerking in a patient i write either alert/obtunded and orientated/confused as they refer to 2 aspects of a persons state of alertness
ReplyDelete