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As an experienced medical malpractice lawyer, I’ve spent a large portion of my career studying medical records on behalf of my clients.  That used to mean hours upon hours of deciphering barely legible notes jotted by doctors, nurses, and technicians and trying to make sense of what they meant.  With the advent of electronic medical records (EMR), reading charts has gotten easier.  But is patient care suffering as a result?

Harder to Alter Records

I’ve previously written about altered medical records and after-the-fact changes to patients’ charts.  When medical records were simply pen and paper, surreptitiously making a change to someone’s chart (which is a felony) was a lot easier.  Now, EMR metadata and audit trails can reveal exactly when a record was accessed or changed and by whom.  EMR are also much easier to read than scribbled handwriting and drawings.

Less Listening, More Clicking

EMR charting has its detractors, as well.  Many programs rely on check boxes and drop-down selections that may not completely or adequately describe a patient’s conditions.  Changing over from older systems to newer software also presents an opportunity for information to get lost or entered into the wrong fields.  Rather than actively listening to patients, treaters are cognitively engaged in typing up their impressions – not unlike texting while trying to have a conversation.

What’s Next?

As time goes by, EMR systems should improve and users will become more experienced.  Hopefully the end results will be better care and a reliable medical history for each patient.

2 Comments

  1. Gravatar for jc

    These EMR records really slow doctors down. When you are concentrating on a medical record instead of the patient more misses and mistakes will be made.

  2. Gravatar for JM

    I live in Illinois and my wife's doctor altered her paper records years after an appointment without noting it as a late entry. He fabricated a test result and he got caught in his deposition. We can't seem to get the authorities to care (Professional License Dept and local police). Interested in thoughts on this.

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