Bill Cayley, Jr,
MD MDiv
With the increasing use of electronic medical records (EMRs) and their ever-so-helpful templates, smart-sets, and forms for capturing information needed to support billing and guide protocols, I fear we are losing the narrative forest for the well-documented trees. Especially in family medicine, we have a long tradition of teaching our learners to appreciate narrative and nuance, and the flow of meaning and story that comes from a patient’s history can give far more insight into what may be going on than one gets from simple documentation of location, quality, quantity, etc. Now, however, our use of EMRs is pushing us more and more to documentation of positives and negatives, rather than story.
Case in point #1: As emergency room documentation has moved toward templates and away from dictation, I have found ER notes growing in length, yet declining in their ability to convey meaningful information. Documentation of an ER visit that in the past was captured by a one- or two-page dictated note, now comes in a eight- or nine-page template document that gives no real clue as to what really brought the patient in or what really happened.
Case in point #2: As EMRs use templates to guide information gathering, how often do you find yourself responding to the template in an office visit, or ordering something “because it is there,” rather than listening to the patient’s story? Continue reading
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