I was asked to consult on a patient on the internal medicine service today. Below is a screen capture of the list of her medications in the dictated H&P. The H&P had been verified by the doctor who dictated it. If you can overlook the fact that the patient was on 22 different meds (not a record for patient on the medicine service, by the way), check out #13 on the list.
Yes, it is the wonder drug _ _ _ _ _. So what happened? For whatever reason, the doctor obviously did not read his lengthy H&P. (Remember, it was a medical patient.) He signed off on it without a glance. Should I ignore this and go ahead with surgery on the patient? What if the drug was Coumadin, an anticoagulant, which is often given in a dose of 5 mg?
What's that you say? Ask the patient? Well, like many patients, she has no idea what medications she is taking. The list was brought in by a relative and is nowhere to be found. Ask the doctor who did the H&P? No, sorry. It's a hospitalist service and she was admitted two days ago. The doctor is off this weekend. Via a blood test, I was able to determine that it was not Coumadin.
Stay tuned for more examples of EMR follies.