Electronic medical records (EMRs) are pretty much the standard these days. What I’ve noticed is that that rather than providing a nice, succinct summary of a patient visit, they really just contain a lot of useless junk that is geared more towards data collection, ticking off boxes to satisfy billing requirements, and legal butt-covering.
Case in point:
I saw a patient recently who is on methotrexate. It’s a wonderful drug used for autoimmune conditions, such as rheumatoid arthritis. It works by inhibiting an enzyme that allows cells to metabolize folic acid, which is necessary for the growth of certain cells. Because of its mechanism of action, it’s completely contraindicated in pregnancy since it will stop the growth of a fetus. Obviously, you need to be careful when prescribing it to a woman who may become pregnant.
Anyway, back to my patient. I got a copy of the note from the specialist who prescribed the patient methotrexate. It includes a very comprehensive accounting of the extensive counseling of the risks and benefits of prescribing the drug, including the risk to pregnancy.
Looks good, right?
Only problem is…the patient in question is a 60 year old man.
I was sure to reiterate to him the importance of stopping the medication before he goes and tries to get pregnant.
On one hand, this is funny. But on the other, it’s really pretty pathetic. It’s a perfect example of how charts have become useless. It also tells me that even if the patient was counseled about methotrexate, this is not proper documentation, because there is no way he was told to his face to stop methotrexate 3 months before trying to become pregnant. That fact brings the veracity of the rest of the note into question.
But when you’re working off a template on an EMR, and you’re just pointing and clicking, it’s really easy to just cut and paste your boiler plate methotrexate summary into the chart.
I don’t have an EMR. And I like it that way. I dictate my notes. And I can guarantee that when you’re doing things the old-fashioned way, you would never document that you discussed the risks of pregnancy with a 60 year old man. Just because something is a bit more technologically advanced doesn’t mean it’s better.