It has a major impact on doctor-patient relations and the potential outcome of diagnosis. If a physician is unable to determine your findings based on what nurses or PA’s have documented, they may improperly treat a patient. Nurses and physician assistants chart constantly so a physician can simply look at the chart to see a patient’s progress. Improper diagnoses from improper charting could potentially send a patient to an incorrect specialist or waste valuable time in critical cases.
Inaccurate or failed recording of information on patient charts, failed follow up on lab tests or results, and medication names or dosage mistakes are also common in the medical workplace. Doctors must communicate clearly with colleagues, but more importantly, their patients. A doctor may repeat questions that an assistant has already asked in an effort to verify what has been written on a chart. Patients may be asked if lab tests had already been done, how long ago, and if they were notified of the results. This ensure the patient is aware of their medical fitness and allows the doctor to also address any questions or concerns. Documenting is not only about writing, but about speaking and listening as …show more content…
Speak clearly with patients and family and avoid using medical jargon. They may not understand medical terminology and become scared that a common condition is far worse than it actually is. For instance, if you visited your family doctor and were told that you have rhinorrhea, oscitancy, a bit of sudation and pyrexia, you may become panicked and begin to think the prognosis is grim and you have to immediately update your last will and testament! Your prognosis in lay terms: you have a runny nose, you’re drowsy and yawning, you’re sweating and have a fever. While you may not feel well, none of those conditions are very serious. Symptoms of a common cold,