Looking up my patient

On Fridays my classmates and I wrap things up at one clinical and drive 15 miles to the next site to get our clinical assignments for Saturday. We're expected to go to the hospital, find the name and diagnosis of our patient and then review their chart for things like medications, diagnoses, vital signs, health history, lab results, interventions, etc. We take that info back home to look up things we don't know and fill out three different forms that we need for Saturday. It's a bit brutal and takes hours to do...lots of fun on a Friday night.

So today I finished my shift at the high-risk prenatal clinic (AKA the "Scare the Shit Out of Pregnant Women" clinic) and headed north. I didn't see any patients with infectious diseases, so I picked out one with a pneumothorax (lung collapse due to air in the pleural cavity) and went to look over their chart. One of the first things I noted was that the patient was a nonsmoker - important because smoking is a risk factor for pneumothorax and for recurrences after recovery. I flipped through the chart, taking notes, and got to the medical administration record (MAR). There were ten different drugs and I started copying the names but then noticed that one of the ordered drugs was a nicotine patch. Why would a nonsmoker have a nicotine patch? I looked more closely at the form and realized that the MAR for a different patient had wound up in my chart. I pointed out the mistake and the unit secretary corrected it.