Notes are the Heart of the Patient Care Process
The problem lies not so much in the mechanics of patient care – test ordering, retrieving results, and documenting simple procedures or writing prescriptions – but rather in recording the subtle nuances of the patient history and the physical exam. The thought processes behind developing a differential diagnosis, even describing a patient’s response to treatment, is an essential component in good note writing.
Creating notes regarding patient care using the currently installed systems is universally regarded by medical professionals as a serious deficit among every major electronic healthcare records (EHR) information management system on the market today. Underlining the urgency in finding a solution is that electronically recording and storing medical records have been federally mandated for all healthcare documentation.
Doctors, nurses and practitioners everywhere complain that they feel more like typists and clerks today.
|Nurse 1: “I hate charting because it’s so time consuming!
The thing I hate most, is when we transport a patient, and it takes more time to do the paperwork than it does to transport the patient (I’m spending more time on the paperwork than I actually spent with the patient!).”
|Nurse 2: “…the reason I hate charting is because I didn’t sign up to type all day.”|
|Doctor: “In my specialty, it’s usual to spend three minutes with a patient and twenty with the chart. That isn’t why I went into medicine.”
– Yahoo Answers
Having much to do with the complexities of providing quality care today, with electronics being the most integral and important tool of our modern age, many doctors have resorted to the additional expense of employing scribes, who shadow them.
Just ask anyone who has visited a doctor recently, where the attention is directed. Is it on a computer screen or on the patient?