Ideally, the computer should outshine paper charts when it comes to the organization and retrieval of health information. With a stroke on the
keyboard or the click of a mouse, a patient’s sequential blood studies, chest X-rays, or mammograms should be accessible for immediate review. The potential errors of a lab report misfiled in the wrong patient’s chart, or a critical lab result that goes unnoticed, should be prevented by a computer-based system of data storage and recovery. Every minute saved from searching through a thick paper chart could be utilized by the physician for direct care of the patient.
Unfortunately, the computer does not score as well with regard to the efficient and effective recording of a physician-patient encounter. Software that is presently available demands that the physician personally input all data, obviating the cost of a transcriptionist, but it dips into time that should be spent with the patient.
The Nursing Assistant inputs that theses were all done where as in fact nothing is done.
Diet Education
Seatbelt Education
Alcohol screen
Colon cancer screen
Annual Mammogram
Annual Colon Screening
Smoking cessation Education and counseling
Suddenly Hba1c has been changed to label
Glycosylated hemoglobin
so much so None of the previous A1c readings show up when you click on the new label
Unfortunately, the computer does not score as well with regard to the efficient and effective recording of a physician-patient encounter. Software that is presently available demands that the physician personally input all data, obviating the cost of a transcriptionist, but it dips into time that should be spent with the patient.
Such programs utilize templates rather than providing individualized narratives of a particular patient’s medical history and physical findings. Templates allow the physician to generate, again with just a keystroke, a huge volume of documentary boilerplate for the chart. A prepackaged Re-view of Systems with what are called “pertinent negatives” can be added to the record of any office visit, in effect making it look more detailed and complex than it truly is. Medicare coding rules permit substantially higher remuneration if the chart is supported through thicker documentation; so, in effect, the doctor is paid by the word. The current appeal of EMR is its ability to support and justify “up-coding” of physician charges by “bombing” the chart with paper. Was the man who was referred to the ENT (ear, nose, and throat) surgeon for a simple nosebleed actually asked if he ever contracted malaria? I doubt it.
keyboard or the click of a mouse, a patient’s sequential blood studies, chest X-rays, or mammograms should be accessible for immediate review. The potential errors of a lab report misfiled in the wrong patient’s chart, or a critical lab result that goes unnoticed, should be prevented by a computer-based system of data storage and recovery. Every minute saved from searching through a thick paper chart could be utilized by the physician for direct care of the patient.
Unfortunately, the computer does not score as well with regard to the efficient and effective recording of a physician-patient encounter. Software that is presently available demands that the physician personally input all data, obviating the cost of a transcriptionist, but it dips into time that should be spent with the patient.
The Nursing Assistant inputs that theses were all done where as in fact nothing is done.
Diet Education
Seatbelt Education
Alcohol screen
Colon cancer screen
Annual Mammogram
Annual Colon Screening
Smoking cessation Education and counseling
Suddenly Hba1c has been changed to label
Glycosylated hemoglobin
so much so None of the previous A1c readings show up when you click on the new label
Unfortunately, the computer does not score as well with regard to the efficient and effective recording of a physician-patient encounter. Software that is presently available demands that the physician personally input all data, obviating the cost of a transcriptionist, but it dips into time that should be spent with the patient.
Such programs utilize templates rather than providing individualized narratives of a particular patient’s medical history and physical findings. Templates allow the physician to generate, again with just a keystroke, a huge volume of documentary boilerplate for the chart. A prepackaged Re-view of Systems with what are called “pertinent negatives” can be added to the record of any office visit, in effect making it look more detailed and complex than it truly is. Medicare coding rules permit substantially higher remuneration if the chart is supported through thicker documentation; so, in effect, the doctor is paid by the word. The current appeal of EMR is its ability to support and justify “up-coding” of physician charges by “bombing” the chart with paper. Was the man who was referred to the ENT (ear, nose, and throat) surgeon for a simple nosebleed actually asked if he ever contracted malaria? I doubt it.
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