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.
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Source: Kevin, M.D. - Medical Weblog - Category: General Medicine Authors: < a href="https://www.kevinmd.com/blog/post-author/philip-a-masters" rel="tag" > Philip A. Masters, MD < /a > Tags: Tech American College of Physicians Health IT Primary Care Source Type: blogs
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