Monday, November 12, 2007

the structure of the chart

I have now used electronic charts for more than a year and a half. The way I look at the chart has changed substantially, because the chart is now much better organized and it is much easier to find data.

However, I look at my "plain" clinical encounter notes less often. In the past, much of the data was located there; for example, I'd have to search to find previous blood pressures or weights. Now, I click a link or look at my flowsheets.

There has been debate about "the patient's story" in the chart; in the past, that mostly meant ongoing longitudinal data in the encounter notes (legible or not). Now, the story tends to be all over the chart; the data is more easily accessible, but it is also more scattered. Some of it is only accessible in electronic form.

Much of my chronic disease management is captured in my flowsheets; the encounter is a poor format for following chronic diseases. For lab follow-up, I am less likely to write "hemoglobin was 88, now it is 97", because that is clickable in the electronic lab. I do put in assessments in encounters, although this is more likely for in-person encounters (for billing) than for phone conversations. I put in reasoning for treatment or investigations, so I can see what I was thinking. However, I will often not put in "DXA ordered"; the DXA (bone density XR) order is a link within the encounter. If I print the chart, the link will show a DI was ordered, but you will need to access the electronic version to see what it was for. Similarly, my lab requests show up in the encounter as a link, and not as discrete blood tests.

The data is generally richer and more extensive (because much of it flows in automatically), but some of it is standardized because of templates, such as a low back examination or a visit for a cold. My annual check ups also are standardized. This probably reflects an attempt to provide good care for everyone, but it does make the record less individual. I am probably conscious of the fact that there will be patient access at some point in the future (and I fully support this), which may make me a bit more cautious about what I write.

I think we may need to start thinking about "the patient's story" in a less linear manner. I am not saying that the clinical encounter document is not important, but it does seem to me that it is assuming less importance; I look at it less. I'm not sure if that's a good or bad thing.


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