Electronic medical records’ unpleasant side effect — “Note bloat”

It happened again today: an elderly lady with critical aortic stenosis with all its cool findings: late peaking harsh, palpable murmur, Gallavardin phenomenon, LV heave – the works! And what did the electronic medical record from the intern picking up the patient say?

“CV – Irreg rate and rhythm, no murmurs, clicks or rubs.”

No doubt this was a documentation macro that was not edited or else the intern failed to examine the patient (or maybe both).

No excuse! It’s time to end the crap being spewed forth into electronic medical records!

I say that every time such a note is discovered like this by our new medical trainess, they fail their rotation. Yep: make the penalty severe and make it stick! That way, they’ll think HARD about what they contribute to the medical record and be held accountable!

Of course there’s a few sticky problems with such a heavy-handed approach:

1. Attendings do not critically review what is actually written in the chart by interns because it is buried in pages of electronic morass and rarely found, and…
2. No one has a clue what to do to attendings who do the same thing. After all, when it comes to getting paid for your work, it’s not about what doctors write in a chart, it’s about how many things doctors write about so they can bill the government for their professional services.

The author, Dr. Westby G. Fisher, is a cardiologist at NorthShore University HealthSystem who writes regularly at Dr. Wes.