Do Not Let Patient Care Interfere With Documentation

Obviously, a dollop of sarcasm there from this blogging physician’s post. Check this out. What you will see is an important piece that documents the history of the “patient record.” In the old days, he notes, the patient record was mostly a doctor’s notes to himself (seldom herself at the time) about the patient that would provide hints on future care. Patient “charts” were rather sparse at the time, even for the most complicated of patients. This, of course, was in the days where the PCP handled virtually all of a given patient’s care. Along come multi-specialty teams with multiple consults, and the use of medical records got more complicated. 

Also in the mix here are the multiple purposes that EMR’s are now supposed to serve. Communication among consulting physicians. Documentation of services to obtain reimbursement. Evidentiary support in case medical legal issues arise. Etc. No wonder there are so many “clicks” that need to be made for each patient.

Bottom Line. However the EMR got to be the behemoth that it is now, this Pediatric Intensive Care Physician is only asking for a record keeping system that does not, literally, take more time to administer for a given case than was actually spent on patient care. 

That sounds fair!

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