the.com/hospital charts
the legal novel nobody wanted to write, updated hourly by people too tired to write novels.
means the ongoing medical record of a patient's history, treatment, and vitals, kept by hospital staff for care and liability alike.
from from the literal clipboard-and-paper chart hung at the foot of a hospital bed, tracking temperature and dosage in an era before electronic records; the word stuck even after the clipboard became a screen.
copy-paste rotstudies find over half of chart text is copied forward daily.
legal weightif it isn't charted, courts often treat it as not done.
time sinkdoctors spend nearly two hours on charts per hour of patient time.
acronym minefieldsame abbreviation can mean different drugs on different wards.
for instance
epic emr — used by roughly 250 million patient records across the us.
soap notes — subjective objective assessment plan, standard chart format since the 1960s.
nursing kardex — bedside quick-reference card summarizing chart data for shift handoffs.