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Medical records were intended to present the clinical care , progress, and thought process in treating patients. With the computer a new level of clear (legible and organized) documentation became possible. This in the light of ever increasing liability in every sector of our society has made the EMR the pinnacle of protection for medical institutions.

The administrative goal of these institutions is to protect their health care delivery from legal problems as much as possible. To this point all employees have the paramount duty of documentation. While this charge is important, the mandate sometimes gets in the way of efficient medical care where decisions require immediate adaptability to change or addition of services, medications or diagnostics.

Recently, I experienced such a situation where my OR patient  required extra fluid which was ordered in a timely manner and discussed directly with the hospital pharmacist(i.e. person to person by phone) but was not prepared because the pharmacy department did not “see” the order in the computer. The order was in the computer, but even so, does not the fact that direct communication between medical professionals take precedence over immediate documentation in an ongoing clinical situation? What comes first? The patient or the chart?

We have lost the humanity, the adaptability and basic trust in each other, especially in a professional relationship, all in the service of the almighty EMR.

 

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