Reading My Documentation
Before computors I wrote all my notes out in long hand and could scrible the "n's" and "m's" or add a dot above the word if I wasnt sure the word had and i or an e.
There was no spell check with red underlnes or grren wavy lines if the sentances didn't make sence. Oh the good old days when mis-spelings were not noticed as easily.
We are getting a new computor at my work. It will contain all the billing, documentation and time in/out for us. The documntation scares me. I am not the best speller nor am I the most eloquant when it comes to therapy phrases to denote progress. I hope it will have spelll check on it, although some of the medical words we use come up as wrong.
And what do I do if I see another co-worker continueously mispell a word? Should I subtley buy a dictionary or pretend the word is correct? And what will happen if a not needs to be sent to the doctor? Do I write it or let the worst spellar do it and really make our department shine?
Some places will use a simple check the box method for progresses notes with limited room for actual writting. This is good but may lack the full extent of a pateints progress. And if we write too much it may set us up for a denial or a lawsuit.
I have also seen too little documentation where I had no clue what the patient did or how they had progressed. Is there a happy medium with documenttion?
P.S. how many mistakes were in this post?