Electronic patient notes, the way they stand now, are dangerous. As physicians wiser and more experienced than myself have noted, they are made for billing, not story-telling and communication between healthcare professionals; and as anyone with even basic literacy in the English language will notice as soon as they read one, they are a barely comprehensible, intelligible, muddled word salad that looks computer generated because, well, in most cases it is.

Why?

For one, they are ridiculously easy to create. Click on a checkbox and every admission note you start will come pre-populated with what the EMR thinks are the patient’s current home medications, prior surgical procedures and such. Have trouble accurately documenting the dozen medications your 72-year-old with systolic heart failure, diabetes, CKD and vascular dementia has? No big deal—the e-patient has at least something listed from an ER visit 9 months ago. You’ll make sure to go back to the admission note later and append it with the correct list when you get it from the family member tomorrow, right? Right.

They also save you from having to type. Click click click, and the review of systems is done. Too much clicking? There is a solution: spend 5 minutes to create a macro, and you will have all your common questions pre-answered as No on all the notes, shaving of seconds of additional clicking. Because asking all your patients the same questions and expecting identical answers is just plain common sense, amiright? Oh, and of course tachycardia is a symptom. It’s right there on the ROS list, waiting to be clicked.

Most of all, electronic notes are the one cure for writer’s block. While in the distant past1 you had to spend agonizing minutes staring at a blank admission note trying to form a coherent story on why the patient came to be seen, and then try putting it down on paper down without feeling ashamed, you learn from EMR that it is OK to sign a medico-legal document that contains this brilliant turn of phrase:

The reason for visit is: pt missed hd, high bp, n/v. The course was: constant. The exacerbating factor was: none. The alleviating factor was: none.

But why? Medicine residents are, in general, all moderately-to-ridiculosuly smart and ambitious people who should know better.

Well, for starters, some of them don’t. Even in the olden days1 you had a couple of interns who weren’t the best ever history-takers2 and wrote poor-quality notes. Electronic notes, unfortunately, help them obfuscate their deficiencies. It is very easy to see in a one-page note how much useful information the resident has actually obtained. Not so much with computer-generated six-pagers.

Then there is your typical smart intern just finishing putting in orders for her fourth admission admission that day after discussing each one with the supervising resident, all while answering a barrage of pages about the 30 patients she is cross-covering. The first two admission notes are almost done—she has to updated the plan after talking with the resident—but the other two will have to wait until she updates the sign-out and hands off all the patients to the night float. This is arguably much more important than notes as it directly affects the care those newly admitted patients will get overnight, while the admission note is not really needed until the following day during morning rounds. She’s smart enough to prioritize.

She’s also smart enough to know what is expected of her. What she know about writing admission notes during residency she learned from her peers, particularly seniors—who concentrated on efficiency —and that lady at the billing department who gave a noon conference talk on the importance of complete documentation for coding. So The Man wants me to be efficient-yet-thorough, and then he gives me this electronic tool with auto-population, templates, macros and such. Hmmmmm

Yes, she might get in trouble if her notes are so horrendously bad to significantly impede patient care. From my very limited experience this just does not happen. Or rather, if it does, appropriate documentation is a single bullet in the long list of areas of improvement during an M&M.

What to do?


  1. Or in my program, six months ago. 

  2. They would be the ones calling the patient “a poor historian”, and were usually correct, although not in the way they intended. Patients are the ones giving a (hi)story, the physician is the historian.