Well, I guess with pediatrics, there is just much less to document. And, I am not the great documenter anyway. I try to make it a policy to always finish the note in the room (in fact always) and even do letters, etc. And, before that sounds egotistical, this is at the expense of great notes and letters. I recall in the past, I think before AC, I used to do two or three letters a day on perfect gray paper which was a 24 thickness. My letters are horrible compared.
On another note, pardon the pun, I was just playing around with an idea that doesn't quite solve everyone's issues, but I still think it's better, because being able to change a note after the fact just isn't safe. One of the reasons it was scary having access to Version 3's database was the temptation to be able to change any note at anytime. And, I don't mean medicolegal as in a litiginous environment, I mean by we, the doctors. I haven't been sued yet, but I have had records subpoenad which I knew weren't being asked for to add to the family scrapbook. Boy, I would have loved to go back and add to a note and document like crazy. And, again, I know two weeks or two months is different than two hours but where do you draw the line? Three hours later? When you just notice that the three week old you saw had a temp of 101.5, and you diagnosed it with a cold and didn't see the temp? If you couldn't get hold of them family, it would sure be tempting to change that to 99.5.
So, if you had to change a note even months later, you could do the following. I know that many of us use Shortkeys, one of the greatest little programs ever. I just made a shortkey for Error corrected by Bert Adams, MD. 9/21/0919:48 using "ee e" (space there so it doesn't add it again. I simply wrote the correct words in the chart and put that underneath. I made a shortkey for This note edited for errors on 9/21/09 by using "cc c" that I put in the chief complaint so it would show up in the past visit section.
Oh, and I forgot to mention, I simply pulled up the same note already saved and added the corrections directly to it. You can either keep what is there and add the addendum directly to the chart with the sig and date/time stamp or actually correct the words themselves. This way you still have the original as an audit.
Again, this isn't the exact wish in the thread, but I thought it may help.
And, Vicki I do understand your having a lot more difficult patients and charts.
