If it’s not in the computer, you didn’t order it

They used to tell us, as physicians, that “if it isn’t on the chart, it didn’t happen.”  We could protest all day, to billing companies, insurers or attorneys, “I did that.  It’s assumed.  I always do the same thing every time.”  But they would retort, “nope, it’s not in the chart.”  So we learned to detail everything, every time, every movement.  Every consideration and justification.  The idea being, our ‘thought process’ had to be clearly elucidated on paper.

Enter the world of computers.  Not only do all of my thoughts have to be recorded, all of my assessments and intuitions, all of my reflections and prognostications, so do all of my orders.  And I mean all of them. Because, as with before, so it is again.  “If it’s not in the computer, it didn’t happen.”

More to the point, “if it’s not in the computer, you didn’t order it, which means the nurse ordered it without an order, which means she tried to practice medicine which means she broke the law and will likely be summarily terminated.  Or executed.  Whichever comes first.”

I notice, increasingly, that everyone who is my ancillary staff is frantic about the computer.  I say “I need a chest x-ray for this gentleman with chest pain.”

“Ok.  Did you put it in the computer?”

I say, “Go ahead and start a liter of fluid and give him 25 mg of Phenergan for nausea.”

I ask later, “did that get started?”

“No doctor.  We’re waiting for you to put it into the computer.”

Dressings, x-rays, labs, EKGs, scans, splints, IVs and everything else only happens “if it’s in the computer.”

What makes it more real?  Is it billing?  Is it the ability of lawyers to comb through it in litigation?  Is it that we have evolved and only recognize the validity of electronic symbols, rather than the validity of the oral or written word?

I suspect the majority of it has to do with culpability.  If it’s in the computer, and there is evidence I have ordered it before the nurse did it, whatever goes wrong can always be my fault.  But in an age of vastly increased computer use, and the inherent risk of error on drop-down menus or in picking the correct patient from the list of many others (in a chaotic environment), will the data entered always be correct even when the nurse uses it?

And will I then be culpable for a thing I didn’t actually order?  And will we find that tragedies happen more because everyone is so focused on the screen that the computer is actually the customer, not the patient?

There were days when our words mattered.  Now they don’t.  Only our keyboards, or our voice recognition transferred to a hard drive.

And I don’t think we’re better off than before.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test

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