Looking at Charts
In many laboratories, outpatients arrive with requisitions in hand or assuming that the laboratory has received them in advance. Laboratory employees enter the orders in an information system and check them in real time or after the fact. But the laboratory has control over this process from beginning to end, with a pretty clear idea of what happened when something goes wrong.
Inpatients are a different story.
Unless the physician orders in the information system, laboratory orders are hand-written in a chart, along with diet, medications, physical therapy, isolation, nursing care, and a dozen other care directives in a stream of consciousness, often barely legible fashion. (Here’s a question: do doctors bother to try to read each other’s handwriting?) These orders are transcribed into the information system by a clerk who may or may not understand subtle differences in laboratory tests (e.g. IgG and IgM). Perhaps, some or all of these charts are audited by nursing after the testing is completed. But the laboratory has no control over this process, with no clue what happened when something goes wrong.
CPOE (Computerized Physician Order Entry) is the Holy Grail of order entry, but there’s no guarantee that an information test menu designed for the convenience of laboratory clerks makes sense to physicians.
Do we have a responsibility to check charts, review orders, and have an awareness of the processes that produce our inpatient orders?
No, I suppose. Outpatient requisitions, for example, may be generated in much the same way or directly by a physician; we don’t know and don’t care, generally. Processes related to inpatient charts are not ours. And thumbing through charts can create turf issues. I vividly remember a nurse getting in my face years ago with a, “What do you think YOU’RE doing?”
But -- significantly -- looking at charts is an excellent chance to improve pre- and post-analytical quality. For example, if an inpatient reflex-to-culture urinalysis is ordered and the urine is found to be contaminated, what happens? It can’t hurt to look.
How many of you look at charts?
NEXT: Antigens and Antibodies