PatrickMD.net

I finished my five-week pediatric rotation last week. I spent half the time on the floor at the local children’s hospital, and half the time in the pediatric ER. Definitely a great experience all around.

The ER is the first hospital location where I have worked that uses paper notes for the entire visit. Reportedly there are plans to change this in the next few months, so I believe I caught the end of an era.

I loved the efficiency of the paper-based system, but the downsides were difficult to read handwriting and poor transfer to the other layers of the form. However, these downsides highlight the reality of an ER visit — past notes are not that helpful. While past medical history is crucial, the history given by patients is often “good enough”. A significant motivator for computerizing the ER is that “good enough” is not sufficient when it comes to something like a critical allergic reaction discovered during a prior inpatient visit.

I believe we can learn something from all kinds of medical records, so here is a description of this ER’s system.

A single 17″x22″ triplicate form (four pages linked together) serves as the patient record for a single visit. The first page is triage data and is filled out by the triage nurse. The second corner is for the clinician’s note. This includes a chief complaint, history of present illness, physical exam, assessment & plan, and a checklist review of systems. The third corner tracks orders requested and performed, and the fourth corner has the attending’s assessment & diagnosis, discharge instructions, and a place for the patient to sign.

The usual procedure for a non-urgent case is for me to pull the chart from the triage rack, call in the patient, do the interview and exam. As I’m doing the interview I check off boxes but leave the written note for later, since I’m still figuring that part out. After I’m done the exam I present to an attending, who comes in with me, replicates the physical findings I highlighted, and we tell the family what we think they should do. From the moment I start presenting to the the attending, he or she starts to scribble a short note on the fourth page. The attending is usually finished writing in a minute or two. I discharge the family with instructions, prescriptions, and pamphlets, and then I write my note. The whole process took me about an hour from start to finish.

While it’s not really relevant from a systems perspective, I found it enormously satisfying to sign the chart and throw it in the “done” bin. I haven’t been able to reproduce that experience when using a computer-based system.

Tags:   emr · paperNo Comments