Our electronic medical records prompt us to do what we do in our patient visits and also in many cases in what order to do those things. We could fairly easily change the order, but it may seem like extra work to do that.
But following the script we are given often seems rude. It can threaten our chance of building a therapeutic relationship and could even keep the patient from answering our rapid-fire initial questions truthfully.
So many initial office visit templates have the drug, sex, smoking and alcohol questions right in front, followed by probing of income, sexual orientation, pain, depression, domestic abuse and many more intimate questions that would be classified as appaling if you were at a dinner party with a new coworker or a first date with someone.
Our medical records serve many purposes, and the most important part of the record, particularly an initial visit, in my opinion, is the patient’s story. The best way to build a relationship with someone you just met is to ask them to tell you about themselves and then to ask follow-up questions to prove your interest.
Once you have taken the medical history and done an appropriate exam for their concerns, it is more natural to say something like “there are some background information we always gather when we see someone for the first time, so I hope you don’t mind if we take care of that also today”.
I think of that data as somewhat like the metadata that’s attached to your iPhone photographs or “Gracenotes” on a music CD. It’s information that can be retrieved if it is needed, but it doesn’t drown out the patient’s story and your clinical assessment and plan.
Of course there are times when some of those screening questions lead you to explanations for the patient’s symptoms or are abnormal enough to warrant a place on their problem list and in that case that part of the screening protocol should get included in the main part of the visit note.
For example, if someone has numb, tingling feet and admits to heavy alcohol use when you get around to asking about that later in the visit, it can open the door to a conversation about alcoholic or even diabetic neuropathy.
Our profession has practiced the art of asking the right questions in the right way and at the right time for centuries. We shouldn’t let non-medical programmers take our finely tuned skills and tools away from us. We need to work around their machines sometimes.
Electronic medical records are a disaster. As you so skillfully point out, filling out checklists in medical records misses so much of what a physician offers a patient in genuine patient-centered care intsead of the PR waving of the hands about patient-centered care.
Absolutely agree.
The way I work, I usually have time to review the patient records. I can fill in information I have onto a MS Word document which has the clinic templates.
Then I’ll start my consultation asking the parent and child what they need to tell me and what they want me to know. I’ve found over the years, that usually tells me everything I need to know! Then I’ll spend the rest the consultation filling the gaps of with essential questions I need to complete to make my diagnostic formulation and filling in the relevant information gaps in the template. Haha, we have laptops we can work with in clinic, so I can now type, talk and look at the patient at the same time, when I’m taking a history. When I have completed my history taking. That’s when my laptop comes off my lap and goes back onto the desk and I can talk with the families about my diagnostic formulations and answer their questions. Basically in the drive for us to be ‘paper lite’ my laptop has become my pen and paper.
I’m all for technology helping us. It can speed things up, it can provide order, clarity and some degree of standardisation. I wrote the autism assessment template for our department but I’m clear it’s a tool we can use but does not take away our clinical judgement and experience and common sense.