Issue 14 / 28 April 2014

UNTIL that moment, it felt like any other day — morning walk, breakfast, shower and off to do a ward round.

Then I picked up the bedside chart of Mr X in Room 3. “Hmm”, I thought. “This feels a little heavier than usual.”

I opened the folder to be confronted by an 11-page document on the handling and disposal of cytotoxic drugs.

Now, you must be thinking Room 3 is in the oncology ward or the patient has some grave malignancy. You can imagine me wearing a special purple gown, mask and gloves.


Mr X is having rehabilitation after a hip fracture. He takes one methotrexate tablet a week for rheumatoid arthritis — a tablet that he normally collects from his community pharmacy and takes on his own at home.

The intrusion of the mega protocol into what should have been a routine morning round made me mull over matters. I realised that over the past few years bigger biceps are required to handle bedside charts.

As a rural doctor, I need to see the essentials in the bedside chart; namely, observations (BP, pulse, temperature, oxygen saturation, blood sugar level and urine output) and medications (what’s been given, if they’ve been given and when).

Pardon my candour Mr Beuro Krat, but I feel other documents can go in the full patient chart at the ward office.

Modern bedside charts are a forest of papers and laminates. The chart pictured (below) shows what is mandatory in our small rural hospital. I imagine bigger hospitals with sicker patients have even more items on their charts.

Since the introduction of the National Inpatient Medication Chart the medication chart seems to have multiplied. Insulins, intravenous fluids and medications for long-stay patients can result in several medication charts.

The premise of all these forms, charts, protocols, notices, guidelines, instructions and flow-sheets is to improve “quality, safety and outcomes for the patient journey”.

However, when the folder becomes as bulky and cumbersome as it now is, my concern is that the patient journey becomes one of clinicians poring over papers rather than (heaven forbid!) the patient being spoken to or examined.

So confusing have the bedside charts become, the potential for mistakes and missing critical data is greater than ever. Add to this the “team” approach that in reality is very piecemeal in many hospitals — with different people prescribing different things at different times — it is little wonder so many mistakes are made in hospital settings.

For example, it’s not uncommon to have a patient in hospital with rheumatoid arthritis, heart failure and diabetes – as well as recovering from surgery. And it would not be considered unusual for such a patient to develop an infection and chest pain.

If you do come across a patient like this on your ward rounds my advice is to discharge the rest of your patients, as you’ll need all day to read this one patient’s bedside chart.

And perhaps you should call the burly security guard to hold the bloody thing for you!

Dr Aniello Iannuzzi is a GP practising in Coonabarabran, NSW.

13 thoughts on “Aniello Iannuzzi: Heavy lifting

  1. Max Kamien says:

    During some country locums I have regular nightmares where I am  trying to climb a mountain with 15-20 administrators and nurses, all clutching a mass of paper and a blue biro, hanging from my belt and yelling at me for my autograph that will magically relieve them of any responsibility. 

  2. glenn murray says:

    I have just gone through licensing , accreditation and credentialling . The paperwork was ridiculous.

    We have allowed ourselves to lose control of the process.  It has been shown that accreditation etc do not improve standards but the RACGP etc still support them .

    With the aging population etc etc money and time are in short supply and these processes need to be practical, efficient and economical. At the moment all they do is make work for bureaucrats with us paying the bills. A committee is the best way to find the wrong answer .

    Evidence based common sense please .

  3. Horst Herb says:

    Common sense would dictate that experienced clinicians decide on how to document, according to local specific requirements.

    It is puzzling that the potential for harm, no matter how little the likelihood, invariably seems to give license to committees designing “solutions” that make the problem far worse without having to be accountable for the consequences and without the clinicians having any clear pathway for “fixing the fix”.

    The Cerner computer record system we are forced to use in NSW helath systems is not fit for purpose at all, and the chimera of those electronic records in combination with horribly designed paper forms that both make it nigh mossible to access information in a timely fashion when required is actively endangering our patients and destroying our work place happiness.

  4. Sue Ieraci says:

    “can someone find a middle path please!” There is a middle path, which is the most efficient one: let senior clinicians write on paper or dictate, and have their records transcribed into the electronic record. That gives you the best of both worlds – efficiency of documentation for the clinician, but legible records for the future. The fixed medical record is rarely needed in real time. transcription services that are completed within – say – one working day will generally do. And urgent letters can be written by hand and transcribed later. The electronic answer isn’t always the most efficient one. 

  5. Petra B Jaiswal says:

    Papers. Bedside charts! Oh how nostalgic it makes me feel!

    Come to Sweden and experience the joys of computerised healthcare. At the end of a working day you will marvel at how you, once again, have spent no more than one hour with actual patient contact. The remaining time you try to work your way through and around technology related complications. Just to get any simple task done. All the time, without exceptions!

    In Australia documentation on paper can get a bit messy, but somehow things get done. Whereas here in Sweden; when the many computer systems fail to work the way we need them to, there is often not much that can be done.

    Both ways are frustrating, can someone find a middle path please!

  6. Kylie Fardell says:

    Thanks for raising this increasingly frustrating problem.  I agree with the comments above.  The irony of so much paperwork is that the important stuff is missed, sometimes with deleterious consequences for patients.  In our hospital at least, there seems to be resistance to having nursing staff actually read the ‘diagnosis’ and ‘plan’ section of the admission note (I don’t expect them to read the whole admission). Instead, the emergency nurse paraphrases the doctor’s (typed) admission onto yet another piece of paper, and this Chinese whispers system has led to errors in treatment.   We take multiple calls about stuff that is in the notes but hasn’t been read because the nurses are swamped with the paperwork they are required to complete.  My impression is that the majority of forms have been created by bureaucrats/non-clinicians.

    I’m not sure how to best address this.  Attempts to sort it out at the local level haven’t been successful because  NSW Health requires most of the forms to be used, but there doesn’t seem to be anyone accountable for actually considering the patient record as a whole, rather than individual forms.   

  7. Sue Ieraci says:

    The other complication in larger EDs is that test-ordering and medical notes are computerised, but nursing observations and notes are not. We, too, once had a triage sheet which also included medication and fluid orders and (hand-written) medical notes. Now we have electronic medical notes and test ordering, nursing observations and notes on paper at the bedside, one paper sheet for ED meds and fluids, and another (multi-page) form for ongoing medications. Oh, for the paperless office!

  8. Dr Hamish Steiner says:

    In my rural ED we use one sheet of paper to record obs, hx, exam, medication etc. For the last 18 months NSW health and the LHD(Local health district) have been trying to move us to a new ED chart. The only downside is the new chart doesnt have a space for observations, so a 6 page ED obs form is required. It has no space for medication, so a 4 page medication chart is requred.So now a simple presentaion, ie stood on a rusty nail requires at least 3 sheets of paper. One for hx, one for the ADT, one for the temperature.

    The ED has run out of space for records, so now we cant access old records easily when a patient presents to the ED. The ED records have been moved to long term storage.

    If we use the new sheets we need to handwrite the patients name about 12 times, allergies about 3 times . Most ED doctors will tell you that duplication and transcribing data from one sheet to another is a risk due to transcription errors. 

    If the ED gets busy there are pieces of paper everywhere.

    Buts thats just the ED.

    For inpatients we have the same situation as Dr Iannuzzi. There are so many pieces of paper in the folder that you cant find anything. The nurses use the nursing plan, and never read what the doctors have written. I understand this, they are busy and the nursing plan is huge. 

    If I want the nurses to specifically do something, ie an ECG, I write in the notes in capitals, then highlight the note with a highlight pen, then speak to the current nurse looking after the patient. That mostly works……



  9. Sue Ieraci says:

    We are seeing the feral side of ”risk management” gone rampant. There is a turning point at which the tasks required for compliance with protocols distract from both the cognitive and physical aspects of patient care. After that point, the protocol can create more risks than it prevents. This is happening in large organisations beyond health care – where being seen to mitigate risk seems to mean more than actual outcomes. Frustrating.

  10. Peter McInerney says:

    My beef which really continues the theme relates to the paper work in our small rural ED. Don’t get me wrong-I think between the flags is a good thing but generally our patients don’t hang around in the ED for 6 hours or more like the bigger centres. Our nurses are “not allowed” enter the presentation obs on the ED triage chart. They have to go on the obs chart in pictorial form ie without actual values and often that chart will be somewhere else. It makes it so much harder to look at a triage chart and get a feel for the acuity of the situation. They have really thrown the baby out with the bath water with this one.

  11. Dr Roger Allen says:

    This is called the Magna Charta and the barons now have clipboards and reside at Funnymede. 

    Common sense is an endangered species. 

    More is less and less is more. We need less not more. I have patients on wound care plans with no wounds.

    The major advance would be if someone read the doctors notes or came with him when he saw a patient. 

    I had a flower lady who changed the patients flowers every day who was the only one who could tell me the condition of the patient and how he was now going to the bathroom unassisted. She was the only continuity of care apart from the doctor. I just wanted some common sense observation; not Magna Charta. 

  12. Stephen Langford says:

    Well noted.  More paper does not lead to improved quality of care and indeed I think the opposite is the case.

    I recently noted a country hospital where a patient attended with a small laceration needing suturing.  Previously this would be a single sheet of paper, describing the cause and nature of the laceration, what it was sutured with and the followup.  Often an ADT was administered.

    To my horror I found a four page drug chart was required and where the ADT is entered is not intuitive or easily visible.  The patient attendance had at least four pages also.

    This is nursing bureacracy gone mad – with no insight into true quality or efficiency in our health services. 

  13. Richard Middleton says:

    Days gone by, the functions mandated (if applicable) by much of this aide memoir/instruction/check sheet were automatically performed by caring competent nursing and ancilliary staff.

    What does this say about present standards?

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