Medical Records | Electronic Technology is Neither All Negative nor All Positive

I wrote a post at my blog account on the DPM Blogs at Podiatry Today about electronic technology for keeping medical records entitled Weighing The Positives And Negatives Of EMR

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I’ve used electronic record keeping in some form for several years. As mentioned in the article, some of the things that are especially appealing is the opportunity to make notes immediately and legibly. I’ve had some concerns on re-reading my notes and reading the notes of other doctors that we become too eager to make extensive notes. Keyboarding is simply easier to fill-in all the possibilities than when we dictate our notes or hand write them. However, too-much-information TMI can lead to confusion and lost time/energy when we have to filter through long and extended notes to get to the real issue.

Some are concerned with the use of templates to complete notes. These tools might be seen as assuming answers and issues by using form options. Surely some cases are very similar, but yet each condition is unique. We can answer these concerns by making templates that aren’t exceptionally complete, but do cover the basics that are typical and could be considered part of a checklist where we make sure we haven’t missed anything. Note areas through-out a template that applies to my practice permit me to make the necessarily unique observations for that case.

The concerns are worth overcoming because of the increased efficiency for my staff when they are working with complete and legible records.

As noted in the original blog post, I see benefit for patients when doctors and staff are using electronic record keeping for greater efficiency in our care process. As medical professionals we are responsible to look at our choice of format to find those which will provide the greatest patient benefit through clarity and efficiency.