Quote:
Originally Posted by NurseKris
I personally like computer charting for many reasons. The biggest one being continuity of care. I like being able to pull up a patient's chart and get a little background and be able to pull test results. When I worked in radiology a certain blood test is needed before we can administer contrast (it's a test that lets us know if your kidneys are working properly). I could look up the result if the patient had the test run either as an outpatient or inpatient. This eliminated time spent calling a doctor's office or trying to reach the patient's floor nurse. Another radiology example is in MRI when the patient had things like a stent placed but they don't have the card that goes with it so you don't know if it is MRI safe or not. I was able to look into the patients chart for not just my hospital but for any hospital in my network and know exactly which kind of stent was placed. This allows us to determine if they can get the MRI or not and which machine they can use.
As far as the diagnosis codes (ICD 10 formerly ICD 9) go they are primarily used for insurance purposes. If the doctor were to order a test or a medication without a code the insurance company would not pay for it. My personal opinion towards insurance companies is not a very high and I feel that have no right to dictate care. To use your example of gout if the test shows you do not have gout the doctor can remove it from your current list of health issues. Sometimes there is no code available for what the doctor did so they have to enter it under a different code. Also since most tests are done to rule out a condition that condition is not listed as a diagnosis just simply a reason for a test. I am not a coder so my knowledge is limited this is just what I know from my experience and both a nurse and patient.
I’m not saying that mistakes are not made, however computerized charting does cut down on errors and makes things easier on healthcare providers. There are always going to be doctors that cheat the system in hopes of making more money. When you find things in your chart that you believe are wrong I would ask about them and see what they say.
My favorite thing about computerized charting is not having to try and read a doctor’s handwriting!  |
Hi NurseKris,
Thanks for your post. It is nice to get to see things from the other side of the coin. I, too, worked in the medical field but before a lot of the changes that have recently developed. (And before electronic medical records.) I worked in an acute unit in a hospital, also ICU and CCU.
I totally agree that having test results, labs, imaging, etc. available in an electronic record is beneficial. A list of prior surgical procedures, medications, etc. is also great to have available if accurate and updated.
And being able to read a typed note, instead of the scribble of many doctors is a definite plus, but what I have found is that is NOT always the case. Some docs are now scanning IN their handwritten notes instead of typing them. That loses one of the Biggest Advantages.
Let me expound a little on what perplexes me about the electronic medical record.
Two of my eight physicians have offered their patients "access to their medical record" online. However, the amount of access is very limited. I have access to my annual exam ONLY and nothing else from one physician. The other physician uses a program that gives the patient access to medication list, dates of office visits with the physician's notes. When I accessed this information, the note for each and every visit was word for word the same paragraph. It sounded like a "canned" paragraph that was picked from a group of possible paragraphs they use that best fits the visit but still very generic in manner. There was a great deal of missing information that is either not available to the patient to see, OR, the charting is VERY incomplete.
The canned paragraph includes information that is different than my experience during the visits. Tests that were performed in the office were not listed nor the results. The physician told me that my condition had worsened at each visit from the prior visit yet that was NOT included in the notes in the paragraph of which I mentioned.
If this is my "complete" medical record, it is VERY misleading and missing vital information. If it is not, then why are parts of the medical record being hidden from the patient? What parts will be shared with other medical personnel if necessary? The part I can view or the entire record?
To bring in a 3rd situation, a third doctor just moved his office practice into the local hospital. He uses an electronic medical record but does not offer access to patients. I have been seeing this physician for several years and have a procedure performed by him several times a year. I got a call from the hospital the day before my scheduled procedure asking for my insurance information. Where is the advantage of the electronic medical record in that? My doctor has that information in my record. The hospital obviously knew of the upcoming procedure, and all my other information, so why did I have to provide my insurance information separately?
From the information I have "SEEN" in my so-called medical record, it is not only erroneous but incomplete and I would sincerely hope that another physician would not rely upon it.
I do agree with some of the points you have made but the flip side is not a positive in my opinion.