Medical records are like your grandfather’s attic…

…Some nuggets, but mostly crap. Adding “electronic” means sortable, searchable, bigger attic, more crap. Unfortunately, no one has the guts to actually clean it. Are urinalyses from the 90’s still important, or are we just being sentimental?

Back to intended effects and side effects… During my emergency medicine residency there was a mandate from somewhere that attending physicians had to see each patient cared for by their residents. While a hard transition, I think US emergency medical care became far more consistent as a result. I absolutely benefitted in my training, and I’m certain my patients did as well.

But then came the side effects. Instead of accepting “seen and agreed,” for legal and billing reasons attendings had to write actual notes on every chart, often using the exact words written by residents on the very same page. “Pt c/o ST. Red OP. No exudates. Heart – RRR, no MRG. Lungs – CTAB. Abd – soft NT, ND. Probably viral. Rec’d fluids, rest, ibu, f/u w/ pmd.” Basically, attending notes became abridged versions of residents’ notes, and for purposes of patient care, further buried the nuggets.

Back then if you requested a patient’s old record, minutes to hours later Igor would arrive, sometimes with 5+ volumes of paper, mostly composed of signed consents, insurance forms, decades old labs, illegible carbon copies, admit/discharge reports, ER logs with resident plus attending notes, etc. Interspersed were the nuggets: current meds, allergies, recent procedures, last EKG, PCP and emergency contact numbers.

Electronic medical records offered incredible opportunity to speed information transmission and improve care. But that promise has yet to be realized. Having worked in quite a few ERs since residency, regardless of which EMR, I find they consistently pull me even further away from patients. I work part time in a wonderful ER today that uses scribes to ease the load. It’s incredible working with these bright-eyed energetic individuals, yet I still spend far more time clicking buttons than with patients. Gigabytes of data are generated per patient, but the nuggets remain scattered and buried. Gathering history quickly from neighboring hospitals or clinics is still no easy task.

As I said in my first post, no one person is to blame and the EMR subject needs far more than a few paragraphs.

But personally, I’ve found my solution which you knew was coming… Pre-R! Because of no coding, billing, collections and insurance, finally I can write concise, logical notes, which I can hand happily to my patients if they desire. No acronyms. Plain English (or Spanish).

EMR, HIPPA, Medical records, Privacy

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