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How Did Our Medical Notes Become So Useless?

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Re: How Did Our Medical Notes Become So Useless?

#61

Post by mikecsh »

samsolomon wrote: post #43

I've done a good bit of thinking about medical note taking. To me it's a little odd that hospitals are the ones who keep this information. I'd think that the records should belong to patients—it's about them after all. And that the patients would provide access to doctors or hospitals. Right now I've got a personal medical journal that has things like: * Sickness - Date Range and Notes * Flu Shots - Date * Injuries -…

The problem with this is that a very small minority of patients are that diligent or reliable, for various reasons (dementia, forgetfulness, disinterest, mental illness, low IQ, substance abuse, not realising the information is required, brought in by ambulance unconscious and peri-arrest, etc.).

Here in the UK patients do have responsibility for some records - notably anticoagulation records and maternity / child health records.

I have seen literally one patient present with their anticoagulation record. I have lost count of the number of patients who come to appointments without their maternity notes or child health notes.

Even trying to get an accurate medication history from a patient is near impossible and we end up having to look at past hospital discharge letters, call their GP, or look on shared record systems to try and piece together what they are taking.

I'm all for patients "owning" their records but they must be held in a way that is accessible when needed regardless of human variabilities.

Re: How Did Our Medical Notes Become So Useless?

#62

Post by Scoundreller »

classichasclass wrote: post #11
ivraatiems wrote: post #2

I strongly agree that EMRs are making this problem worse, not better. And doctors seem to hate quite ubiquitously the extra amount of documentation they have to do. While there is a lot of evidence in some areas that EMRs have improved quality of care and patients' lives, I don't think this is one of them.

I was working for a large multi-state HMO during their transition to a major EHR (I'll let you guess, since I do not speak for either). I have a background in IT and was a systems consultant for a number of years. On paper, I could get a relatively uncomplicated chest pain case from the ER to the hospital unit with all the orders for workup ready in 45 minutes. With the EHR, we had abominations like double medication…

What is a “double” medrec?

And what initial electronic order sets were implemented? Did the organization not just implement (as best as possible) the previously on-paper order sets?

It’s not a perfect approach (you can do things with an online form that you can’t do on paper and vice-versa), but it seems like a good approach to avoid (more) mass confusion on Day1.

Re: How Did Our Medical Notes Become So Useless?

#63

Post by magnetic »

arielweisberg wrote: post #3

Medical notes are largely fiction IME. You should request all your medical records from any doctor you have seen and start demanding they correct them. You will be shocked at the lies they tell about you. You will be even more shocked down the road when you find out how these lies can hurt you.

I found omissions to be particularly interesting too.

For example, I once declined to take a shot after the doctor explicitly told me that it would most likely not yield any benefit, given the response I had from other treatments.

The medical record simply shows that I declined the shot, but not that this was upon strong recommendation from the doctor.

This became an issue later when the provider went back to the records and stated "you were offered this shot and declined". It is technically true of course, but context would tell a slightly different story, and would definitely shift more responsibility towards the doctor.

The doctor was probably right to make this recommendation, but the fact that it is not captured in the records makes me uncomfortable.

Re: How Did Our Medical Notes Become So Useless?

#64

Post by tivert »

limeblack wrote: post #32
jermaustin1 wrote: post #30

Earlier quoted context omitted.

That's amazing. I guess, in the US, we only started tracking patients recently. I had to call and have my old records faxed from my old GP in Texas to one in New Jersey, and then again from that GP to my NEWER one in New York. Earliest record was from when I was 7, since neither my mother or I remember who my pediatrician was before then.

I disagree on this stance. If you were diagnosed with depression when 13 but no longer depressed its nobody not the doctor, the nurse, the IT staff jobs to know this unless you choose. You have everything from Psychology/Psychiatry notes to overdose records that many health staff can pull up from almost any computer. EDIT: Remember many jobs disqualify you from the job if you have any past psychiatric treatment. Even…

Not necessarily. Some places segregate psychiatry records from general medical records, and won't send them unless specifically requested.

Re: How Did Our Medical Notes Become So Useless?

#65

Post by organsnyder »

yumraj wrote: post #24

My kids' pediatrician was part of a small office, which merged with a larger office that is affiliated with a large hospital and hence uses EPIC. She used to take hand notes on paper and was quiet efficient when she was with the smaller office. After the move I have seen her struggle with EPIC, and then recently hire a medical transcription service and be followed by a person taking notes so that she can focus on the…

Believe it or not, Epic is one of the more provider-friendly solutions out there, according to many providers I've talked with (I work in the healthcare software industry).

Re: How Did Our Medical Notes Become So Useless?

#66

Post by [deleted] »

dvtrn wrote: post #19
rhcom2 wrote: post #10

Earlier quoted context omitted.

In the US you're legally entitled to your medical records too but every time I've done it the response is always defensive, ie "why do you need them", "send me the doctors information and I'll fax it to them myself".

every time I've done it the response is always defensive, ie "why do you need them" I was asked this once after requesting mine. I flatly said "I don't", and waited. The person on the other end of the line was clearly thrown off by this, probably expecting something they could dish out a canned response to, hoping I'd give up. It was obvious from their voice they were scrambling for what to say to that. A bit of rigm…

[deleted]

Re: How Did Our Medical Notes Become So Useless?

#67

Post by RyJones »

arielweisberg wrote: post #3

Medical notes are largely fiction IME. You should request all your medical records from any doctor you have seen and start demanding they correct them. You will be shocked at the lies they tell about you. You will be even more shocked down the road when you find out how these lies can hurt you.

At one point recently someone noted on a X Ray that I had hepatitis. I asked my PCP; he said don’t worry, we don’t diagnose that with radiology.

I asked that it be removed.

No can do.

AFAIK I’ll go to the grave with a note from a random radiologist that I have hepatitis.

Re: How Did Our Medical Notes Become So Useless?

#68

Post by RyJones »

howard941 wrote: post #44
jghn wrote: post #18

Earlier quoted context omitted.

A while back I had a doctor where you could access everything via the online portal. I don't think some of the employees there realized that as there was some truly shocking stuff in there. One thing I learned was that anything I said which could possibly be misconstrued in a negative light was noted in my record as if the negative connotation was accurate.

I think you're being too kind. The person taking notes was (or should have been) trained to listen for and accurately record admissions against interest. If it ever wound up in court stuff like this is presumed to be highly reliable because reasonable people are disinclined to admit to negative things. This sort of thing highlights the need for broad and bulletproof physician-patient privilege.

When I carefully read my records, I saw a bunch of random errors. I asked my PCP and surgeon how that happened; they said “probably transcription errors”

I don’t have a lot of faith in the quality of the records

Re: How Did Our Medical Notes Become So Useless?

#69

Post by sxg »

Scoundreller wrote: post #51
sxg wrote: post #40

Earlier quoted context omitted.

Many departments do standardize their note formats. The problem is that the note is directly connected to billing, and the billing requirements are absurd. I'm a medical student, and I recently visited my PCP for a medication refill. I have no significant medical history whatsoever, and the visit took no more than 15 minutes as expected. A month later, I was given a bill for $330 stating my hospital visit was level 4…

Why did a visit to your PCP get billed as a hospital visit? And which acuity scale was this? Usually the higher the number, the less acute you are.

I meant outpatient visit. My PCP is in the main campus of the hospital, and I wasn’t being rigorous with the terminology.

I’m using the CPT codes within the site I linked to. 99211–99215 are the codes that correlate to acuity, with 99215 being the most acute. I am aware of other systems like level 1 vs level 2 trauma centers. In that case, yes the level 1 is higher acuity. Maybe that’s what you were thinking of?

Re: How Did Our Medical Notes Become So Useless?

#70

Post by tivert »

rhcom2 wrote: post #10
arielweisberg wrote: post #3

Medical notes are largely fiction IME. You should request all your medical records from any doctor you have seen and start demanding they correct them. You will be shocked at the lies they tell about you. You will be even more shocked down the road when you find out how these lies can hurt you.

In the US you're legally entitled to your medical records too but every time I've done it the response is always defensive, ie "why do you need them", "send me the doctors information and I'll fax it to them myself".

> In the US you're legally entitled to your medical records too but every time I've done it the response is always defensive, ie "why do you need them"

Whenever I've been asked, I just say "I want them for my files," and I've had no problems.

Sometimes questions like that could actually be an attempt to be helpful. For instance to send along only the needed records rather than a fat file full of extraneous info or save the patient the trouble of being a middleman between two doctors.

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