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Old 03-12-2021, 01:27 PM
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But nowadays documentation more important than counselling.
E.g your chest pain guy, if you document "return advice/red flags given". You are safe even you didn't actually do it and pt dies.
Conversely, if you did tell him Abt the red flags/return advice but didn't document, he dies of mi, you can still be sued.

I just left the system but when I was mopexing in ops/Ed/im, my seniors/consultants always say documentation is king.
Osteoporosis counselling and bisphosphonate initiation when I was in gm, our documentation is 2 pages (talk Abt all risks, benefits, side effects, alternative, mechanism of action, follow up, failure of treatment etc) but the actual conversation with pt is less than 1 min ("we give you med to strengthen the bone ah, sometimes can cause stomach problem but will give you med also, don't worry")

. We can write so much simply because there is a smart text/template specially designed for such purposes (I guess is to protect us from lawsuits lol)

In Ed there is even a special tutorial for all mopex on "documentation to protect oneself as in what sort of thing we MUST write for certain presenting complaint, but no tutorial on comms skills lol.
Exactly. Documentation is king. If you document it is done. If not documented means not done. There is no video recording or audio recording (not allowed due to privacy issues).

Templates is the way to go. Nobody got time to spend 15 minutes talk to patient say many things then spend another 15 min writing long journal entry write like dear diary what the patient and I talked about like scribe. Btw nobody pays for all the time spent on documentation.
So have template. Standard all the things supposed to say all there. Never say also documented. Ass covered. Play the game. The practice is medicine is now dictated by what the lawyers say we should do.

All this stuff theough is never really taught in med school because it would be scandalous. All those idealistic academia are the worst. I pity young drs as they have to learn from their own mistakes and getting into trouble or see their colleagues get in trouble.

There is another pearl. A patient who is happy because you listened to him and did what he wanted he got what he wanted will never complain even if you never followed guidelines and what not. But a patient who is unhappy cos he didnt get what he want even if you follow guidelines CPG protocol whatever will complain and probably cook up things say you rude you arrogant you incompetent stupid etc. Complaint is always bad no matter even if you are right. No complaint is best. But everyone knows if the way you practice is all patient happy one and no complaint means you probably not following guidelines lah

Do be careful. Make sure what you do for patient to make them happy is not illegal. And also not one of those clear cut violate SMC rules one. Also dont cause harm to patient. Otherwise try to keep patients happy as a rule.
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