Another day, another article blaming EMRs (electronic medical records) for the sorry state of medical documentation today.
The latest, “We are in the age of copy and paste medicine”, blames EMRs for the fact that medical providers are producing useless, inaccurate clinical notes because it’s easier to copy and paste a previous note’s history/review of systems/exam/whatever into your current note than it is to actually write a new note.
I can’t deny that EMRs make it EASIER to create useless notes. But the EMRs aren’t the ones creating these notes.
It’s time to stop blaming EMRs for our crappy documentation, and do something about it.
What can we do about it? We can START WRITING BETTER NOTES.
Sure, maybe this means it takes another couple minutes to finish your note. Do I find note-writing to be one of the most onerous tasks of my day? UH, YEAH. It’s a pain, it’s tedious, it sucks. But it’s part of my job.
I owe it to the patient, who took the time to come in and share their story with me, to write that story down somewhere. I owe it to my colleagues, who might see that same patient when she comes back in a week, to write down what I saw the first time around. I owe it to my future self, who might see the patient for a follow-up visit in 6 months, to write down my current and prospective plans for managing that patient’s care.
Back when computer illiteracy was a thing, and a decent percentage of health care providers were still technology novices, there was an argument to be made about how EMRs made life oh-so-hard. I’ve actually lived this: My first job as an NP was with an office where the implementation of an EMR, and the (questionable) decision to adopt temporary-but-actually-permanent schedule reductions for our more slow-to-adopt providers, resulted in the financial ruin and closure of an otherwise thriving primary care practice. That. Sucked.
So yeah. Copy-and-paste notes are terrible. Illegible template-based notes are terrible. Agree, agree, agree.
But we’re not powerless here. Like any form of technology, the EMR is just a tool. It’s up to us to decide how we’re going to use it.
You don’t like your colleagues’ templated, copy-and-paste notes? Tell them. Maybe they don’t realize how bad they are. Maybe being called out will inspire them to start creating less useless notes.
You don’t like your own templated, copy-and-paste notes? Don’t write them. Every EMR I’ve worked with has a free-text function.
The first step in recovery is admitting you have a problem.
The sooner we all admit that we share at least as much blame in producing lousy notes as the EMR developers do, the sooner we can start fixing the problem.