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Tag: Diagnoses

My Ideal EHR

flying cadeuciiGive me technology which improves my life and that of my patients, or give me death.  Medical records must be informative, efficient, and flexible; like the physicians they serve.  For me, a medical record does not contain just a collection of problem lists, prescribed medications, and immunizations; it is a noteworthy account of the health care provided to another human being over a lifetime.

Recently, I attended a baby shower of a patient who is now an adult.  (I am a pediatrician.) I brought her medical chart wrapped with a satin bow as one of her gifts.  I was her physician for many years; my father had taken care of both her and her mother as children.  Her growth, development, immunizations, and illnesses were all recorded; but so were 25 years of life experiences, trials, triumphs, and tribulations.  The back section contains drawings she had given me, newspaper articles of her achievements, graduation announcements, and her wedding invitation.  Obviously, medical records register growth parameters, vital signs, and sick visits; but they also encompass my relationship with my patients.

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