Signing Off

We have a joke at the clinic that the only type of paper that doesn’t need a doctor’s signature is the toilet paper. We are constantly scribbling our abbreviated signatures on incoming x-ray reports, specialist’s consultation reports, ER reports and lab results. Once signed, these papers get filed in the patients’ charts, and may never be looked at again.

Unsigned reports, paper clipped to the front of patient charts, clutter countertops, shelves and desks throughout the office. There is great pressure to just sign off on them, so they can be put away.

But out of sight is out of mind.

At the nursing home, rounding doctors open their folders and find stacks of lab results, some x-ray reports and the occasional consultation note. Each piece of paper gets a few seconds’ attention before it gets signed off. The charts are not pulled, and the system more or less assumes that each doctor knows the “story” behind each lab report he quickly scribbles his signature on.

But sometimes we get the results of a test ordered by one of our colleagues. What if we don’t notice and sign off anyway?

On a sweltering August afternoon at the boarding home across town I had seen Roger Greary, a sixty pack-year smoker with high blood pressure and borderline kidney function. He was short of breath just walking to the dining room and he had a hint of ankle swelling. I ordered some bloodwork, which included a screening test for heart failure. My handwritten chart note outlined my plan on how to proceed, depending on his test results.

Last week, rounding on a couple of the other residents, my folder contained a request from an oral surgeon to clear Roger Greary for several extractions under anesthesia. I asked to see Roger’s chart and saw my note about his increased shortness of breath.

Flipping to the laboratory section of his chart, my heart sank as I saw the markedly elevated BNP level, a sign of heart failure, signed off by another doctor while I was out on vacation.

I ordered an echocardiogram, started him on furosemide, increased the low dose lisinopril Roger was on for high blood pressure anyway, and jotted down a quick reply to the oral surgeon that we needed to take care of Roger’s heart failure before giving him the go-ahead.

At the office this afternoon I signed off on a stack of prescription refills, more than twice the usual amount, since two of my colleagues are away at a medical conference in Boston. One of my oldest patients needed a routine refill. As I flipped through his chart, my eyes landed on a complete blood count done the day after I saw him last.

His white blood cell count was 30, three times the upper normal limit. The differential showed a “right shift” without atypical cells, so it looks like chronic lymphocytic leukemia, which we wouldn’t treat unless he developed symptoms. But I don’t remember thinking about CLL when I signed off on that report, and it is definitely my signature. Did I scan the report too quickly and mistake his new white count of 30 for his old hematocrit of 30, just a sign of his chronic, stable anemia? Did I sign off on it while listening to a nurse tell me some urgent news about another patient?

Fortunately, my elderly patient is coming in again very soon, and I will be sure to check this out thoroughly, but I have become sensitized again to the dangers of signing off on too many lab reports in too little time.

Signing lab reports is important work, and sometimes we only get one chance to do it right.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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