da Goddess makes an important point - good clinicians accept help from every member of the health care team. I prefer that the nurse tell me the information, because most nursing notes are uninformative. If I took the time to read every nursing note, I would get frustrated. So when the nurse learns something potentially useful, he/she should tell me.
Dr. RW confuses history taking with the absurd current techniques for documentation - The decline in the art of history taking. He has ranted about EMRs recently. Earlier this week he wrote
The authors noted that the illegibility of the old handwritten doctors’ notes has been replaced by a new form of electronic illegibility: template generated clutter. A few clicks of the mouse generate paragraphs of repetitious, boiler plate verbiage with a low signal to noise ratio leading to reader fatigue.
I believe that he is confusing two phenomenon. I do use an EMR at the VA hospital. I understand why we have the cut and paste feature.
EMR allows one to bill a higher fee for the same work with less effort. Our arcane documentation requirements - see Coding Clinic 99232 - reward us for documenting more history and more physical exam pieces. They are supposed to pay us for greater complexity, but only if we record several organ systems for both history and physical. Since documentation means money, the EMR allows legitimate upcoding.
We could fix this problem if we could change the documentation requirements. I would not blame this problem on EMR, the EMR just enables us to get paid more.
But I must separate documentation from history taking from documentation. EMRs do provide cluttered notes. I personally have a template that includes the medication list and the labs from the past 24 hours. These data inform my notes. I finish every note with impressions and plans. Hopefully I make my thoughts clear in those sections.
But history taking is not about documentation, rather it is an exercise in understanding. Through careful history taking, we understand who the patient is, what complaints the patient has, and possibly what likely caused the complaints. We do not often record the nuance of the history. We rarely have time to include all the details of our interrogation. We should act on both the nuance and the details. This is the lost art that we must protect.
Do not blame the decline in history taking or decision making on the EMR. Such comments make one sound like a Luddite. Neither should we champion the EMR as the solution to quality care. The EMR is a tool that makes data retrieval easier, makes orders legible, and makes it easier to spot laboratory trends. We must learn to use the EMR as another tool in our toolbox. When used properly the clinician can find truths, avoid unnecessary testing and quickly review old records. When used improperly, we move around electrons without creating meaning.
Holly
May 6th, 2008 / 10:24 am
You wrote:
“…da Goddess makes an important point - good clinicians accept help from every member of the health care team. I prefer that the nurse tell me the information, because most nursing notes are uninformative. If I took the time to read every nursing note, I would get frustrated. So when the nurse learns something potentially useful, he/she should tell me…”
Amen. This is something that smart residents should learn on their first week of training: you open your eyes and your ears, listen to the nurses, the EKG techs, the orderlies, etc. I learned to get along with everybody during my training, and this worked beautifully, with my patients, attendings, senior residents and, of course, the nurses, particularly those on the night shift, who would call me only when they could not handle minor problems.
Yes, the surgical residents who were [as per Da Goddess] “intimidating” and aloof, would get called about every fifteen minutes…
Good nurses who can communicate properly in English, are invaluable; they do understand that patients come first. Petty territorial disputes, all too common, sadly, will not go away, particularly when some nursing school professors openly tell their students that they are better than doctors and that it would come the time that RNs would be the primary medical practitioners.
“Da Goddess” has one good point and several offensive ones, going on to write about doctors “…scratching their heads and digging through books..” when she already knows everything, as her notes prove.
Thorough medical histories and physicals are ideal; however, they are done mostly on med schools. In real life, time does not allow for them, particularly when you have twelve patients in the waiting room…
Holly M. Wagner, M.D.