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Tag: Auto-populated notes

What Do I Do If I Don’t Have a Template?

Screen Shot 2014-11-03 at 11.49.29 AMElectronic medical records (EMRs) now play a part in the daily documentation routine for most physicians. While improvements in access to patient data, legibility of notes, and ease of order entry are welcome enhancements, there is a significant downside to EMRs as well. Although I’ve blogged about my frustrations with nonsensical, auto-populated notes and error carry-forward, there is a more insidious problem with reliance on EMRs: digital dependency.

The idea of digital dependency first occurred to me during a conversation with a young medical resident at a hospital where we share patients. I was bemoaning the fact that I was being forced to use hospital-designed templates for admission notes, rather than a dictation system or carefully crafted note of my own choosing. She looked at me, wide-eyed and said:

“You’ve worked without templates? How do you even know where to begin? Can you really dictate an entire note off the top of your head? I couldn’t live without templates.”

As I stared back at her with an equal amount of bewilderment, I slowly realized that her thinking had been honed for drop-down menus and check boxes.

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