Today was an amazing day, full of thought-provoking discussions. One of the minor points of discussion was the electronic medical record, and the sheer amount of information that it gives us. I think that the EMR can provide a false sense of complacency, and this can be a very dangerous thing for doctors and their patients. At the beginning of intern year, I spent at least an hour before rounds reviewing everything in the chart, then going to see my patients with the small amount of time left before rounds. Now, I go see my patients first, and then use the rest of the time to review the charts. Sometimes, this means I don’t get to read every bit of information in the chart, BUT I do get to spend an adequate amount of time with the patients and their nurses. There is so much information that does not end up in the chart that is vitally important to taking care of the patient. Previously, I’ve developed the entire plan for the day before seeing the patient, and then I have to scrap the whole plan because my conversation with the patient and exam of the patient changed everything. The EMR does not provide adequate context for the objective data it provides, and the context is vital to developing an appropriate treatment plan. Now, I go into my patients’ rooms without any preconceived notions, and I let their concerns guide my treatment plan for the day, with adequate supporting data from the chart. I think that this will be an incredibly valuable lesson for future learners as well who are also tempted to rely too heavily on the EMR. Not all answers can be found in the EMR, and the patient should always be the primary source of information.
