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Electronic medical records

This morning was my twice-a-year visit to my internist for blood work--check the cholesterol, the thyroid (both being treated with medication), and liver function (because of the cholesterol medicine). I also mentioned again that the tailbone pain from last August (that started sometime in February 2007, but I didn't get in to the doctor until August) was still present. Better, perhaps, after taking extra aspirin for inflammation and sitting on pillows to keep pressure off it, but still there. He's referred me to a non-surgeon orthopedist, perhaps headed for a cortisone injection to see if that helps. Yikes! Googled the orthopedist, and find that he is actually a Physiatrist--new term for me. Double yikes! His practice has a YouTube video of their doctors and staff. [shakes head] What's the world coming to?

But that wasn't really the interesting part of the visit. Since my last visit, this clinic has made big strides in converting to electronic medical records. During my check-in I was handed a print out of my Medication Profile, and asked to make any corrections on it. (They missed one of the two prescriptions, by the way.) My doctor worked mostly from a sheaf of printouts of (I assume) previous visits, with only occasional dips into his hand-written versions on the other side of the folder. He hand-wrote his notes, but then stopped before we were done to pull up my record on a monitor in the exam room, type in some stuff, check the results of last fall's X-ray of my coccyx (and print out a copy for me--lovely, it spotted nothing with the coccyx, but notes 'degenerative disc disease at L5-S1', lower back). I asked about the whole electronic records thing, and his frustration is with the input time--I'm not sure if he has to type in his own notes, but he did mention that he must personally deal with each prescription refill, removing any older ones and putting in the new. Only RNs and MDs are allowed to deal with that. I suggested that the next wave of doctors wouldn't make any notes with pen and paper, but he's skeptical...but then, he graduated from medical school in 1965. His habits are pretty well set. <g>


Mar. 19th, 2008 03:50 pm (UTC)
My long time friend from college, Nightengalesknd, is a new doctor (about 9 months into internship) -- types all her notes. Had a hell of a time convincing med school this was a good idea -- but her residency program? 'well. Are the notes going to get into the chart? Yes? Well, okay then!'

She's slowly corrupting the whole of the program.


Nancy Barber

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