Why do we physicians chart the way we do? Hopefully, we do it perfectly well and have no concerns at all. But where I practice emergency medicine, we are approaching maximum inefficiency in charting.
It all became much clearer when we started using our new EMR system. Let me make it clear, I’m not against EMR. In fact, typing and templates work better for me than dictating. My dictations were usually a mine field of blanks and misunderstood words.
Furthermore, if I wanted to use it, we have a new voice recognition dictation system in addition to our templated chart. Though admittedly, the voice recognition program clearly hates some of my partners, as evidenced by the way they grasp the screen and yell at it (‘Chest Pain, not west rain!’) and by its inexplicable use of profanity in the occasional chart.
But I digress. The problem as I see it is the evolution of the medical record. Why does the medical record exist? Read more »
*This blog post was originally published at edwinleap.com*