When it comes to charting our outpatient medical records, I have certainly seen the full-spectrum over the last 25 years.
Initially, we used handwritten progress notes. Then, to make things a little more efficient, we began using templates for some of the paper notes for such things as well-child examinations and physicals. These templates were a series of checklists, and they did make things easier.
Next came dictating into a microcassette recorder. The recordings were sent out to a local person, who transcribed them and sent them back once a week. We would then add those notes to the paper chart. The notes looked nice, however, the process was somewhat costly and the delayed access to records was not optimal.
In 2005, we switched to an electronic medical-record system. The first year of changing was painful, as we had to populate the new record system with patients’ past history, social, family history, etc., which was tedious and time-consuming. And it forced us to become typists. Fortunately, I can type — but not very accurately, and correcting typos slowed me down. But over time I became more efficient and even began to like several aspects of the electronic medical record.
At that point, however, another problem arose. Our electronic-records company decided to no longer support the system we had been using for 10 years and we were forced to change to a completely new system. In other words, the technology that had become my friend was about to become a thorn in my side!
Again, back to square one. Of course, only minimal history and data from the old system could be merged with our new state-of-the-art EMR. This meant going back-and-forth between both records for a while. Basically, we had to populate much of the new EMR ourselves.
In one sense, it was a good way to relearn each patient. However, it was a tremendous amount of work, and it was tiring and time-consuming. Productivity was down for the first month while we adjusted to the new system. In fact, it took a solid 15 months before we had seen most of our patients, usually when they came in for an annual, to update their records
While getting the new system up and running, I often prepared the records the night before so that the visit could go a little more seamlessly the next day. Even with the new system, I still found myself struggling to complete my notes before going home. Many a night was spent on the couch with a laptop, completing my notes from that day or the day before.