Tuesday, February 18, 2014

Dr. Orthochick: When EMR goes bad

So in our EMR, you can just copy and paste the note you wrote from the previous day and add or subtract as needed. Which means it takes 3 seconds to write a note, because generally not much changes over the course of the day. The downside to this is, if I want to read someone else's note, I'm stuck sifting through three weeks of respiratory culture results and discontinued pain meds until I actually get to the "plan" section, because all of that stuff carries over. Plus when the note is copy-pasted, I get the feeling no one else can find the stupid plan either, including the person writing the note, because it is not particularly helpful since it doesn't get updated all that often. Don't get me wrong, I love being able to see what everyone else is writing from my computer at home, but I would love it even more if reading all this gave me some grasp on the overall plan for the patient, instead of 5 days worth of sodium values.

Anyway, the other day I got paged down to the ER at 4AM to evaluate a lady who was having arm swelling and numbness after falling. I had pretty low suspicion for compartment syndrome but I had no idea what it actually was, so I checked her compartment pressures, they were normal, and I discharged her with a prescription for Norco. As luck would have it, she came back, (again while I was on call) and I still didn't know what was wrong, except by this point she was also having numbness and tingling in the other hand as well. I did a CT of her cervical spine (normal) and then gave up. She got admitted to internal med, I wrote a note saying I had no idea what she had but it wasn't a surgical problem.

I was on call on Wednesday and I got paged to do a consult. I spoke to the consulting physician and it turned out it was for the same patient during the same hospitalization.

Me: I've already seen her. Twice. We didn't really know what she had, but it didn't seem like a surgical problem since her nerve symptoms were diffuse and she didn't have compartment syndrome or a drainable hematoma or something like that.
Internal med doc: Oh, I'm sorry. I didn't realize Hand Surgery had already seen her.
Me: If you want, I can see her again to see if anything's changed.
Internal Med Doc: No, you don't have to do that if you've already seen her. I don't think anything's changed.

See, the thing is, everyone's note, from the initial internal med doc who saw the patient 4 days before that to the internal med doc who consulted me, contains the phrase (and I quote):

"Hand surgery has evaluated the patient and feels no surgery is indicated. Appreciate hand surgery input."

Seriously people, you don't have to read my note, but you could at least read your own. I'm sure that was just carried forward from the last guy to write a note, and I know it's a pain to write your own note, but I'm not going to be too impressed if your own note acknowledges that I've already seen the patient you consulted me on.

I'm not saying the EMR is a bad idea, because I think it has a lot of potential, but I'm not sure it's working out quite the way it's supposed to. There's no point in having easier access to records if we're not reading them to figure out what they're saying.


  1. My favorite is when I take the time to write a specific plan for the day on Friday, and when I come back Monday the chief and senior have copied Friday's note for the last two days

  2. {{sigh}} Sorry! Has to make you crazy.

  3. Be careful. I got mixed into a really bad M&M case as an intern, where I had copied and pasted the note and part of the exam (and I HAD examined the patient and noted the finding, and taken the appropriate steps) was leftover from the day before. The patient ended up dying of the complication (bowel rupture) and everything was reviewed and there was my note saying "abdomen non-tender, normal bowel sounds" 5 minutes before I'd ordered a stat abdomen film. It was inexcusable. The only worst part was that the attending co-signed the note so....
    I use templates now but I DON'T cut and paste the physical exam anymore! (and I carefully read trainees notes before I co-sign them, as the attending!)

  4. My centre doesn't use an EMR for daily progress notes - and it seems for good reason. We aren't always great about writing a note everyday, but it's impossible to copy-paste anything (though you certainly can use general information from prior notes).