Patient history

Two takes on this today.

Robert Centor: “Do not blame the decline in history taking or decision making on the EMR. Such comments make one sound like a Luddite. Neither should we champion the EMR as the solution to quality care. The EMR is a tool that makes data retrieval easier, makes orders legible, and makes it easier to spot laboratory trends. We must learn to use the EMR as another tool in our toolbox.”

Dr. RW: “The whole thing, of course, is driven by economics. The less time you have to spend on the H&P the more patients you can see, the more procedures you can do and up goes productivity.”

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  • Anonymous

    I looked at two admissions of the same patient 2 weeks apart. The initial eval, by the same doctor,evidently done by computer rather than dictation, had identical CC, HPI, dx,plan and exam–everything but the current meds. Even the vital signs and recorded verbatim statements by the patient were precisely the same–evidently a cut and paste job.

    That would never have happened in the days of the ink pen and before the current E and M system. They guy would have just written a brief interval note for the second admission explaining why he came back and any pertinent findings.

    I was unable to find out why the patient was readmitted, but I do, however, know something about the professionalism and integrity of the doctor that I didn’t know before.

  • Anonymous

    One thing that integrating the CPT coding requirements into the EMR while the industry is developing is likely to do is entrench the CPT structure in place in perpetuity.

    Makes my skin crawl.

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