My hospital switched over to having all inpatient notes available to patients now. And wow, I’m noticing so many mistakes. And all of the mistakes seem to be pinned on the patient. Why is this?

Ex: I asked if I could have something for anxiety, as I was really worried about sharing a room. Provider said yes. When I was being moved to the room, I asked the nurse for it. Nurse said “can I give you Lyrica instead?” And I said that’s for nerve pain, won’t help.

Note says I was offered Amitriptyline and refused to take it, so they were giving me a one time dose of Ativan. That isn’t really what happened...

Another instance was when the attending asked for me to tell the nurses each time I had a BM. Sometimes my nurses were busy for several hours and missed documenting some of them, or I’d tell them about 2-3 and they’d document just the one they saw when they came in.

When the attending visited each morning, I reported the actual number to her. My chart however says “patient’s report is disputed by what nurse’s saw and documented” and challenged my report of having diarrhea given that nurses reported fewer BMs than what I did.

Why do we always lean toward the patient being incorrect? Especially during the height of the pandemic, when everyone is running ragged at 150% capacity and only 50% of their staff? Is it out of the question that the nurses and doctors made mistakes?

Please be mindful when you’re documenting these things. These mistakes can look small and inconsequential, but they can all build toward a narrative of the patient being a bad historian.