One of my favorite consultants is an orthopedist. His reports consist of five lines or less. The reports are handwritten, but the penmanship is exquisite and easy to read (could he really be a physician?) He writes “Patient complains of …, my findings are …, my impression is …, and I plan to do the following…”
What else do you need? The patients love him. Why not? He spends his time getting a history and doing a physical—not writing notes with his computer.
However, I am an internist/cardiologist, and cannot get away with five-line reports. My handwriting is that of a typical physician. So when I look at my note two weeks later, I say to myself, “What was I thinking? I can’t read this writing.”
The purpose of physicians’ notes is as
1. A record for the physician to refer to in order to keep track of history, medication, positive physical findings and diagnosis.
2. A record to be shared with consultants and when there is a change in physicians.
Note: There is nothing in the above list that refers to government regulations, and other silliness.
The common complaint regarding electronic health records (EHRs) is that their cost is excessive, and the entry of data is time consuming. But there is more. We spent many hours in medical school learning how to take a history. One of the points that was drummed into our skulls is, “Do not just listen to the words. Be alert to non-verbal body language. The patient may say one thing, but indicate something else by his or her body language.” How are you going to see body language when your eyes are glued to the computer?
We have to correct the above problems, but still recognize the computer’s value. The notes are printed and legible. You have a great record of the patient’s current and previous meds. You no longer have to spend a fortune to save old charts. They are all stored electronically. There is one concern; major solar flares occur about once every century. The next one will destroy all our electronic records.
So how did I fix this? I solved the cost by using free software. Yes, there is free software for your medical records, and you can use your old computers to run it. The program I have is excellent. There is one minor drawback. There is a small block of advertising on one side of the screen. It is not intrusive. Can anybody beat this?
I do not use this program as it is designed. That’s because it is designed to please the government, and since it follows government rules, it has its weaknesses. I enter my patient’s history, and for review of systems I enter only the important negative findings. ”Meaningful Use” is a total waste of our time, and is not good medicine.