Doctors using electronic medical records

sunnyflorida
Wed, 10 Aug 2011 17:09:42 +0000

Entries in medical records can never be changed once they are signed off on. One can enter an addendum that will show a timestamp of the date and time of the correcions but the incorrect result will forever be there, and could possible go out to others without the addendum.

A letter of explanation to an insurance company will usually work. But I can see someone getting denied for insurance/life insurance based on an incorrect entry, and that person might not ever know why or be able to correct it.

There is much good about an EMR/EHR. But there are problems. Big problems.

I am contemplating using a scribe, a medical assistant who will tick on the bubbles, etc and answer the questions electronically as I ask the questions. As a woman, I often do not need a “chaperone” in the room during history or physical exam taking. I can ask and get answers to personal questions, and patients feel comfortable. So now I either have to sit and ask and enter into the tablet or desktop, or have a scribe in the room to do it for me. It is rather discrete to sit or stand and take notes. I could quickly dictate afterwards or write out an impression and plan. The technology changes everything. And there were times I would talk, and write down answers in a delayed fashion when the questions got personal. The patient did not think I was writing down every word. Now, she will know that I am entering the data, there will be no thinking and hoping my handwriting will be decipherable only by me, and she will know that all those secrets are there for anyone in the office to see, including the high school and premed college students volunteering to get hours…