Electronic Medical Records (EMR) - Is It All There?
In the summer of 2008, I was fortunate to travel throughout the Midwest and the east coast. My job was to audit charts. I audited both paper and electronic medical charts, and listened and spoke with physicians and nurses. Being a nurse who likes to analyze what works, what doesn't work and why or why not, I learned a lot about electronic medical records.
Have people walked behind the scenes in a medical record's office, where the paper charts are stacked from the floor to the ceiling,in what appears to be alphabetical order, or alphabetical disorder? Doctors often prefer it to the electronic health record systems that are merging with the paper records.
With good reason, I spoke to a doctor in a clinic in Kansas City, who quoted, "I refuse to have electronic medical records. I'm afraid something will be missed if we change over, and try to scan all the documents." Some of his charts were over 3 inches wide. They were very thorough, and he was proud of his documentation. In the same office I spoke with the nurse who was charting on paper, and she had a very interesting aspect, "Besides missing something by not scanning the document, we might forget to put a blood pressure or temperature in the computer. Not all patient information is written in the chart, and that is scary. It is almost like double charting."
At a near-by hospital, the charting was done almost completely in the computer. The charts were audited in the computer, as well. Some of the documents stored in the computer were poorly scanned. And some of the documents should have been in the computer but were never scanned in the first place. This is exactly what the doctor was talking about.