Navigating with Nurse Derrick

Whether you’re the patient or the patient’s family member, keeping a notebook and a pen as tools for your stay could be the difference between getting better once you’re discharge to getting readmitted for the same issues over and over again. This post sets up with a quick summary of why the notebook is so important, followed by a more detailed “day in the life” illustrating the notebook’s importance.

• Quick summary of the notebook’s importance
• Typical day in the hospital
• Interdisciplinary team meeting
• A world where everyone is doing their jobs perfectly
• Which staff member is in charge of coordinating?
• It comes down to you

Quick summary of why the notebook is so important.

1. You’re going to have a bunch of questions pop up as you consider the best and worst possible outcomes of your hospitalization. When the doctors make their drive-by visits to you, you’re probably not going to remember all of those questions before the doctors are already on their way back out again. They will have said their plans at you and already be burning rubber out of your room before your brain can check itself. If your questions are already in the notebook, they’re quickly accessible and you can get them out before the doctor and team hurry out of the room. You’ll be able to keep their focus a little bit longer to answer the questions you wanted to ask them. 
2. Most likely, you’re not going to be able to remember all of the plans each doctor has for you. Without writing them down, you may drop important details, add your own verbiage which may then change the meaning to the next team. Plus, you’ll have a difficult time being able to relay important details to your loved ones when they have questions. 
3. When you (or your loved one) is discharged you’re going to have follow up appointments with other providers who weren’t in the hospital with you. They’re going to want to know what went down during your stay. Having your notebook will help you accurately convey events so that you don’t drive these new providers down unnecessary avenues. That, in and of itself, can save a lot of time and money, as well as help you get the important care you need in a more timely manner. 

A typical day in the hospital

A typical day in the hospital is going to have a lot of teams coming around. General surgery and orthopedic surgery are going to show up early before they start their cases. Most surgery teams will as well. They may be there at 6am before your daytime RN even starts their shift. Nephrology and the ICU team will round between 8am-12pm depending on where you are on the unit. The cardiology fellow will round with their advanced practice provider (a physician’s assistant or a nurse practitioner) around the same time, but often starting a little later in the day. Infectious disease and neurology might show up around 12-2pm. The hospitalist will show up between 2-4pm asking you or the RN what the other teams are thinking because none of the previous teams have put a note in yet. Then the endocrine doctor will swing through between 5-7pm looking like they are on their way to the jazz club (IYKYK) when they’re done with your visit. Finally, the cath lab interventionists are going to come through around 7:30-8pm after they’re done with their cases. (The timing will be different everywhere, I’m sure, but you get the point: lots of different medical teams, personalities, and communication styles will be spread throughout the day.)

Interdisciplinary team meeting

Do they all talk to each other about your case in some kind of daily interdisciplinary team meeting to coordinate care for you? No, the doctors do not come together like that for most patients. It would take a lot of time and would minimize the number of patients they can help. (There are nursing/pharmacy/case management teams who do the interdisciplinary meetings, but the doctors from different disciplines aren’t in those with each other.) The hospitals where I’ve worked have used an electronic record system that has an area where doctors, RNs, physical therapists, and other providers can place progress notes. It’s where they put their plans so everyone who is working on your case can see them. It is also incumbent upon them to read everyone else’s plans so they can know what others are doing. You should have access to these in real time through programs like “My Chart.” If you’re not sure if you do, talk to your RN about it. They should be able to help you in setting it up if it is something your hospital offers.

Now do all of the doctors read each other’s notes? Unfortunately, no. Doctors are humans too. No group of people has every member doing everything perfectly all of the time. There are good ones and there are well intentioned so-so ones. (And there are bad ones. They’re human. It’s the way it is. Consider what you call the person who finishes last in medical school…You call them doctor.)

Imagine a world where everyone’s doing their job perfectly

So let’s imagine a world where all of the doctors are doing it perfectly. (I think this is where a lot of non-medical people start with their expectations of healthcare workers.) They’re each putting in a progress note and they’re each reading each other’s progress notes. Everyone’s on the same page, right? …Still, probably not. Within any written communication comes reader bias, human error, and time delay. 

While some doctors put their progress notes in as soon as they’re done with an individual visit (bless them), some other teams will round on all of their patients and once done with the last one, a resident (who has been taking feverish notes while trying to learn from their attending, and attempting to offer important insights that shows how good at the job they’ll be one day) sits down and writes the progress notes for all of the patients they saw that day. It could be 7pm before the noon visit progress note is in. The issue here is a time delay. Also, that resident could have missed things in their notes, accidentally left something out, or just flat out misremembered what they wrote (human error). And then the person reading them could get caught up in some typos from the other provider’s note and misinterpret the plan (reader bias). 

Which staff member is in charge of coordinating all of this care?

Now whose job is it to coordinate all of this care and stay on top of it? Why, it’s the RN’s job, actually. One of the many responsibilities we have is to coordinate care. In the ICU this is easier to do because I will have two patients and they’ll be close to each other. Barring any emergencies I can make myself available when the teams come by and I can interview them regarding their plans. I can then pass those plans on to other teams as they come through and catch them when they are planning similar or conflicting things. On the other units, it’s a whole separate endeavor and completely impossible to achieve. There’s no way to be able to track in real time what’s happening in 8 different patient rooms or each team’s plan for each of those rooms. Especially not if I’m also performing the usual tasks of my job (responding to emergencies, assessments, medication administration, responding to patient needs, convincing patients it hasn’t actually been 2 hours since they ordered their food, etc).

So it comes down to you

I bring that up because this is another place where the notebook becomes your failsafe tool in managing your care. It can serve as a net below a big hole in the system that is your healthcare. You may write down bits and pieces that don’t immediately make sense, but the RN can help clarify them for you. Or the bits and pieces might inspire a phone call from one doctor to another to get clarification. It is, in my opinion, the most important tool to keep with you to expedite your stay and minimize human errors along the way. 

Will anyone of these providers be relying on your notebook to manage care?  No. But having it there and your involvement in writing things down will help you manage what might be missed. You’ll have your questions at the ready. You’ll be able to clearly communicate what is happening to your concerned family members. And you will be ready for your outpatient follow up appointments. 

Bring the notebook and keep it nearby. You will need it.

Thank you for reading. Did I miss anything? Do you have any suggestions or testimonials? Did this bring up any stories you want to share? Please reach out to me through the contact page if you feel like I missed anything, if this blog has helped you in anyway, or if this brought up a story you’d like to share.