I saw it begin to happen in the ’90′s. Residents came to rounds with their daily notes produced on a word processor. The notes were impressive. Legible, lengthy and meticulously detailed at first glance.
Then I started to notice a pattern. The impressive notes began to look very much alike. The thorough exam varied little from patient to patient. And problems that occurred on previous days seemed to persist in the medical record, even when it had resolved. In some cases the previous day’s note was printed only to have one or two additional elements added by hand. It was never really clear what was worse: the lack of effort or the illegible writing.
Our electronic health records (EHR) offer similar options. We can smart text our way to clinical efficiency. Some doctors have entire impressions and elements of the history pre-generated for common conditions. These are advertised features of the most common EHRs. Technology can make us look more thorough than we really are.
The adoption of automated documentation carries the risk that we make all patients look alike. The drive for thorough documentation comes with the failure to convey what’s happening with a patient. In some cases this is a consequence of laziness. Other times it’s a technique for survival in a regulated world that asks more and more of a doctor’s bandwidth.
Medical documentation should reflect the unique characteristics of every patient’s story. As physicians it’s important to avoid the empty clinical narrative that technology makes easy. As educators it’s our responsibility to medical students and residents to see to it that this transition to EHR brings with it the clear thinking and individualized documentation that was necessary with pen and ink.
*This blog post was originally published at 33 Charts*