It occurred to me that I have been venting, recently, on a tear about my encounters with third parties that, well, are not dazzling me with their brilliance. Perhaps, in the spirit of full disclosure and honesty, I ought to own up to a couple of episodes that tell one and all why my pencils no longer have erasers. Here’s one recent experience.
When I first encountered electronic medical records (EMR), many, many years ago, one of my precepting physicians walked me through his office’s EMR. In the course of his narrative, he observed that, “One of the follies of the EMR is that it will allow you to thoughtlessly chart very stupid stuff, easily and repeatedly. You have to be careful of that, or you will look like an idiot.”
I was reminded of that physician’s wisdom the other day. I had a gentleman in my clinic, seeking care for a sexually transmitted disease (STD). He reported that he had been notified by his paramour that she, the paramour, had been diagnosed with some STD or another, and therefore he would require treatment before another round of Happy Fun Times could be arranged.
Cool. I performed my exam, obtained the specimens required to verify the particular sort of affliction that had been visited upon him, and ordered the appropriate medications. Then I sat down to chart.
In order to save charting time, I have a pre populated template, citing various common or normal findings. I reviewed my template, preparatory to signing off on this chart and moving along to the next patient, and noted my common finding of “post nasal drip”, “runny nose’, and “sore throat”.
I corrected these entries, thinking at the time, “If you have a runny nose, sore throat, and post nasal drip because of your venereal disease, you are likely way, way too sick to be seen by my midlevel self!”