Adding “electronic” means sortable, searchable, bigger attic, more junk. Unfortunately, no one has the guts to actually clean it. Are urinalyses from the 90s still important, or are we just being sentimental?
For everything we do in medicine, there are intended effects and side effects. During my emergency medicine residency there was a mandate that attending physicians had to see each patient cared for by their residents. While a hard transition, I think U.S. emergency medical care became far more consistent as a result. I absolutely benefited in my training, and I’m certain my patients did as well.
Then came the side effects. Instead of accepting “seen and agreed,” for legal and billing reasons attendings had to write actual notes on every chart, often using the exact words written by residents on the very same page. “Pt c/o ST. Red OP. No exudates. CV – RRR, no MRG. Resp – CTAB. Abd – soft, NT, ND. Likely viral. Rec’d fluids, rest, ibu, f/u w/ pmd.” Basically, attending notes became abridged versions of resident notes. They added nothing to patient health, but further buried useful information and slowed care.
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