Pseudo H&Ps and Other Pitfalls of the EMR

The latest Green Journal has an outstanding piece by Dr. James Bernat regarding the unintended consequences of the electronic medical record (EMR). I’ve used this blog and other venues to complain about some of these issues from time to time, but this paper summarizes all of them on once place.

I think one of the highest-level issues is that the clinical relationship has been transformed into a series of billing exercises, with documentation ever more clearly geared toward billing (and “quality”) requirements and ever more removed from human narrative.

What really drives me crazy in particular is what Dr. Bernat calls “pseudohistory”. This is when the EMR application takes a series of checkboxes and turns them into “narrative”. Example:

The problem is acute. The problem is constant. The problem is improved by nothing. The problem is worsened by exertion. The problem is . . .

When I see that garbage in a note, I know that I basically can’t trust anything written there.

Please read this essay!

About Justin A. Sattin

I'm a vascular neurologist and residency program director. I created this blog in order to share some thoughts with my resident and other colleagues, and to foster my own learning as well.
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One Response to Pseudo H&Ps and Other Pitfalls of the EMR

  1. Georgios Manousakis says:

    I have been noticing the consequences of copy-pasting in students’ and residents’ notes more and more recently as an attending. There are even more annoying examples than the above.It has become by pet peeve to see a note by a medical student in the ICU, describing the patient’s neuro exam as: “AAOx3, non-focal”, when we are consulted for an unresponsive patient.
    I am not sure what is the best strategy to prevent this phenomenon. Once something becomes a bad habit, it is easily perpetuated by the individual. I would only emphasize to students and residents that they need to take some pride into what they write down. Anything that bears your signature at the bottom of the text reflects your thinking about the patient’s condition- it’s not a mechanistic process, and, particularly for neurology, it cannot be always incorporated into electronic “templates”.

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