June 16th, 2010 by Edwin Leap, M.D. in Better Health Network, Health Policy, Opinion, True Stories
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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*
November 23rd, 2009 by Edwin Leap, M.D. in Better Health Network, Humor, True Stories
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The patient has fluferculosis, buperculosis, conbumption, arg!
I’ve dictated charts since I started private practice 16 years ago. Although I like to think that I’m pretty good with the English language, it turns out that when I speak it, I mumble, slur and frequently dictate things that make no sense to the transcriptionist.
A standard chart for me might look like this:
‘This 44-year-old_____ complains of several days of ______ severe in the_______right______explosive and sudden in quanset. (Unable to understand physician)….and stated that she(he) {please clarify} would not be short of ______ usually has no pain in _____ when she (he) falls onto the crown?’
Now, this is difficult enough, as you might expect. And often worse when I’m finishing a night shift, and the chart says ‘the patient is awake, alert and sleeping quietly at discharge,zzzzz.’
But voice transcription takes it to a new level. Read more »
*This blog post was originally published at edwinleap.com*
July 26th, 2009 by scanman in Better Health Network, True Stories
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via The Trial of a WhiteCoat – Part 14.
The radiologist that read the film had a habit of going to the surgeons the following day and asking them what they had found. He would open up a blank report so that it looked as if it was dictated at the time of the exam, but would then hold the reports as “preliminary” and finalize them after dictating in the results of the surgeries. That way it looked like he had picked up on all these small findings before anyone else knew about them. He was a decent radiologist, so no one seemed to mind that he was adding all these findings after the fact. Now it burned me.
I’m offended.
No.
That’s too light.
I’m pissed off as hell.
I believe the Americans call this kind of thing “Monday morning quarterbacking.”
Whatever you might call it, this is cheating in my book.
I don’t know why they let that radiologist get away with this kind of behaviour.
Moreover, I can’t believe that anyone would take the man’s reports seriously, leave alone the surgeons that he got information from. If by chance I was a surgeon in that hospital, I would intentionally throw him red herrings.
In case you haven’t been following Whitecoat’s account of his malpractice case, see previous posts of his epic saga here. Far better than reading any crime/legal thriller, cheap or otherwise. John Grisham could take lessons from Whitecoat.
*This blog post was originally published at scan man's notes*
