Physicians must reclaim the medical record

A guest column by the American College of Physicians, exclusive to KevinMD.com. I recently saw a new patient who came to our practice following a lengthy hospitalization. He is in his 80s with a fairly complex medical history typical of many in this age range. Yet, after carefully sifting through my first introduction to this gentleman — a 32-page discharge summary — I was completely unable to glean the circumstances that led to his hospitalization. Amid the completed tick boxes, auto-populated forms, a recurring list of medical problems, and a printout of every medical and nursing order written and medication administered during his hospital stay, every few pages I found a couple of sentences of text that were clearly propagated from previous entries with either very minor or no changes whatsoever. Continue reading ... Your patients are rating you online: How to respond. Manage your online reputation: A social media guide. Find out how.
Source: Kevin, M.D. - Medical Weblog - Category: General Medicine Authors: Tags: Tech American College of Physicians Health IT Primary Care Source Type: blogs