Friday, April 20, 2012

Missing My Anesthesia Cheat Sheet

We are a few months into our new electronic medical records and I have to say I have grown to like it very much. It does make work a lot easier for me. Everything is just a few clicks away, if you know where to look. Preop orders? One click to pull up the prefilled order form and one click to sign it. Done. History and physical? One click to get the template. One click to fill in past medical history. One click for past surgical history. Click, click, click. Sign. Done. It really is a time saver, at least for anesthesiologists.

However one I thing I do miss is having the actual paper H+P in front of me during a case. As a byproduct of all the convenience of clicking in a patient's history, I tend to forget details about the patient. I'm the kind of person who remembers things better if I write it down first. Now I don't ever actually write anything down and it gets kind of tough to recall what I just pasted into my electronic assessment.

For instance, the surgeon may ask what antibiotics the patient is receiving. Nowadays I really don't have a clue. I have to log into the computer, open the patient's file, and look for the patient's medications list. What allergies does the patient have and what are the reactions. Again, log in, look up the patient, and check the allergies list. How tall is the patient? Same routine. Same delay. Same tedium.

During the paper and pen analog era of physician records, all that would be in front of me on my handwritten H+P. That information would  be no more than a few seconds away from me, a quick glance at my quickly scribbled note. Now that is obsolete, never to return again. I can't help feel that some intimacy is lost between a patient and his physician when the doctor can't even remember his height and weight. But at least we are getting more efficient at dehumanizing our patients.

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