Today we had a conversation/debate over guidelines telling us not to name people in our charting.

If you talk to a doctor about needs for patient, you would say "spoke with provider" not "spoke with Dr. Samson"

I disagree, the charting is the narrative that proves I did my job.

The idea behind "provider" is that chart indicates who was servicing that patient. My argument to that is that often times there are multiple providers MD/NP/PA and different specialists too.

Thoughts?

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That seems like odd advice. I suppose there are times when it doesn't matter which doctor. But records should still be as complete as possible. There's no telling how someone may need to rely on them in the future. And putting in general descriptors instead of specific names could give the appearance of records being purposely obscured.

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I am solely responsible for my charting..it is ultimately my license. I will always continue to chart how I feel is best. I agree that multiple providers are at times involved in the complete care of a patient. We should be able to chart as to what we did and who we spoke with.

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Sounds like something coming from the backend maybe linked to lots of litigation maybe and malpractice

I agree with manager 1 above. I have never been told that before but in my opinion I would still continue to chart the way that you see best. It makes more sense to me to say the name of the provider like you mentioned than to just say spoke with the provider, because that could be any provider.

That’s odd for sure why would you not name the provider for reference doesn’t make sense whatsoever

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