Not lost, but I've had a lot of trouble with information being captured incorrectly.
Things like date are pretty commonly messed up. I've also had doctors and nurses put their own, incorrect, interpretation on information I've given them when they repeat it to others. When I say "my child wasn't eating and drinking normally and had half of what they normally do throughout the day", it's incorrect to say "the patient didn't eat or drink all day". That's the type of shit that can look really bad if it's recorded and looked at later. But it's like nobody cares if they record things correctly.
I've also had trouble with people not doing anything with important information. Like maybe you should slow down on the morphine and oxy if the patient is answering fewer basic questions correctly than when they came out of surgery. But it's OK if they can't tell you their own birth date - just give them more and later order a CT ro check for a stroke. Sorry guys, but it should be pretty obvious you're putting them into a opium stupor...
I've noticed recently that there are people out there who simply can't accurately listen to others and repeat back what they say. It's not about being stressed for time, the skill is just not there. You say ABC, they write CBD, and they have no idea it's not the same thing.
OpenNotes can help a little with this, but only if the patient or one of their caregivers has the time and ability to do a detailed review of every chart note.
Things like date are pretty commonly messed up. I've also had doctors and nurses put their own, incorrect, interpretation on information I've given them when they repeat it to others. When I say "my child wasn't eating and drinking normally and had half of what they normally do throughout the day", it's incorrect to say "the patient didn't eat or drink all day". That's the type of shit that can look really bad if it's recorded and looked at later. But it's like nobody cares if they record things correctly.
I've also had trouble with people not doing anything with important information. Like maybe you should slow down on the morphine and oxy if the patient is answering fewer basic questions correctly than when they came out of surgery. But it's OK if they can't tell you their own birth date - just give them more and later order a CT ro check for a stroke. Sorry guys, but it should be pretty obvious you're putting them into a opium stupor...