When it comes to organizing medical records, being detailed oriented is essential. Medical records come into our legal nurse consulting office all states of organization and disorganization. We organize records before reviewing them or forwarding them to our physician and nursing expert witnesses. Attention to details means that you recognize that the patient was admitted to the same hospital two months or two years apart, and that the two admissions need to be separated. Being detailed oriented means that you note the admission and discharge dates and pull out test results that don’t fit within that range. Being detailed oriented means you spot inconsistencies. For example, I saw a progress note that a male patient was diagnosed with ovarian cancer. I don’t think so.
I used to think that I could teach a person to be detail oriented. I can teach how to look at an addressograph plate to figure out the room number and date the patient was admitted. I can teach how to use cover sheets to not the beginning and end dates of an admission. But a recent experience has made me realize that I can’t instill the quality of being detailed oriented. You have it or you don’t.
Three little words in a medical record illustrate the importance of being detail oriented. In the autobiography, Stolen Innocence, Elissa Wall shared her story of being forced into marrying her cousin, at age 14, when she was part of the Fundamentalist Church of Jesus Christ of the Latter Day Saints, a radical offshoot of the Mormon Church. This sect practices polygamy. She brought a suit against Warren Jeffs, the leader of this group. In the closing argument of that trial, the defense attorney said, “Her medical records list the following items checked off: Nutrition, alcohol, drugs, OTCs and vitamins, smoking before pregnancy, smoking currently, and second hand smoke.” Elissa was flabbergasted by what she saw as the defense attempt to paint her as a monster. The prosecutor was detailed oriented. He zoomed in on the medical record the defense attorney had tried to use against Elissa and showed the jury three little words were printed above the list of items: “Not a concern.”
Are you detail oriented? How has that helped you? Do you think it is possible to teach someone to be detailed oriented? Send us a comment. Share your experiences.