A few years ago, I wrote a KevinMD blog post about how cumbersome it was to complete notes in the electronic medical record (EMR). I proposed a solution in our residency clinic but encountered resistance in the adoption process that eventually led to its abandonment. For someone just trying to solve a problem, it was very frustrating, to say the least. Despite the advances in the past few ...

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If you are a physician or know a physician or have ever visited one, chances are you have probably heard them complain about technology in health care. More to the point, they are likely to be complaining about the one piece of technology that affects their lives minute-to-minute: the electronic health record (EHR). To get a sense of how central EHRs are to our daily routines, consider that physicians now ...

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Several patients seen in our practice recently were significantly and dramatically transformed by the electronic health record (EHR). And not in a good way. Take, for instance, the patient whose outside chart was reviewed when she showed up in our office for a follow-up appointment after an emergency department visit. The notes from the emergency department providers, including a scribe and the ...

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As a hospitalist, like most in health care, I am afflicted by the slow march of thousands of mouse clicks on the electronic health record (EHR) every day I work.  But after starting a new job and learning a new EHR, I have become painfully aware of the volume of alerts that pop up when I place orders.  Don’t get me wrong: I appreciate being informed that a patient has ...

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First came the SOAP notes. They’ve nothing to do with cleanliness, just the opposite. SOAP stands for: Subjective, Objective, Assessment and Plan. S: “Patient states that pain is 16/10, sharp, unremitting. Feeling like a crocodile is eating insides every 10 minutes, after sprinkling them with Frank’s hot sauce.” O: On entering the room, patient is eating Cheetos and drinking Mountain Dew while texting. Abdomen is soft and nontender. A: Abdominal pain, probably gastritis. P: ...

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STAT_Logo With nearly 80 percent of internet users searching online for health-related information, it’s no wonder the catchphrase “Dr. Google” has caught on, to the delight of many searchers and the dismay of many real doctors.

What’s received little attention from physicians or the public is the company’s quiet metamorphosis into a ...

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The purpose of clinical documentation is to efficiently communicate critical data to peers in a readable fashion while meeting compliance and billing requirements. This documentation should not represent a data dump. Physicians continually increase our dependence on technology as the digital age deluges us with data. Accessing the right information at the right time is essential to providing appropriate care. The tsunami of new evidence necessitates clinical decision support, yet we ...

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In the mid-1990s, I was working as the medical director for a national computer processing company that had the medical policy and utilization review contract for many Medicaid programs in the United States. Within the first few weeks of being hired, I was invited to attend an IT meeting where the computer project supervisor was going to show off a beta medical reporting program the company had developed for an ...

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A lot has been spoken and written about clinical documentation already. In spite of that, many hospitals still struggle in getting the best out of their doctors when it comes to documentation quality. And although we can cite various reasons for this, we can all safely agree that the hospital EMR is the single biggest influence when outcomes to efficiency and quality of documentation — both in terms of compliance ...

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5,177. That's the current number of "cc'ed charts" as of this morning in my electronic health record in-basket. While it might sound like a lot, this is not at all an unusual accumulation, partly due to the fact that I receive a notation every time a patient at our practice gets a flu shot, and also every time one of my patients or ...

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