Tuesday, October 9, 2012

Worst History And Physical Ever, Thanks To EMR

Click to enlarge
I was looking for my preop patient's history and physical written by a consultant in our new fangled EMR system the other day. Scrolling down hundreds of notes from physicians, residents, fellows, nurses, physical therapists, social workers, etc. I finally located what I wanted. At least I think it's the preop clearance note that I wanted.

Reading through this note felt like the worst case of cutting and pasting I have ever come across. It appears to have come straight from the hospital billing office. The only thing the note was missing were the ICD-9 codes after each unspecified diagnosis. How can a physician produce a history for a patient and label virtually every diagnosis "unspecified"? It makes you wonder if the patient actually has the disease or whether the consultant was too lazy to write more specifically in his note. In other words, this H+P was total garbage. Thanks to our new EMR, this kind of shenanigan is all too common.

Yes we can read doctors' notes more easily now. Unfortunately, what's typed in makes even less sense than before.


  1. Do you think it saves time though overall using EMR though? The other benefit is being able to access the records from any computer since it gets really frustrating when the patient gets wheeled of for some test along with their chart for 3 hours.

  2. Oh yes, I save a ton of time with the new EMR. However I've noticed that between all the cutting and pasting and clicking on buttons, I have much less retention of my patient as compared to before when I had to write down the patient's history on a piece of paper. For the life of me I can't seem to remember a patient's height and weight unless I write it down somewhere. And don't even ask me about a patient's medication history. With a simple command all the patient's drugs are listed automatically, thereby eliminating the tedium of writing them down one by one. But then I can't remember what a patient is taking when somebody asks me what drug he takes for hypertension. So EMR's are a mixed bag. They do increase efficiency but they definitely take something away from the doctor-patient relationship.