The presentation of lab data in EMRs can sometimes be especially annoying. I recently saw a patient who arrived with a long list of alphabetized lab reports: "MCV, Monocyte %, Na, neutrophil, plt, protein ..." and so on. Presenting the labs alphabetically had effectively shuffled together a CBC, basic metabolic profile, and whatever other test results the patient had. Even a junior medical student wouldn’t do this. I scrolled and scrolled, hoping to find some meaningful assessment of the patient’s problems and progress, but I just couldn’t find anything to show me that some thought went into the lengthy final product.
I frequently get hospital discharge summaries that don’t include the date of the patient’s discharge. How lame is that? Often, I have to try to reconstruct hospital events from the information I can glean from the patient. One long rambling note included the very helpful assessment and plan: "Mary was seen today for other."
The Zenith slogan proclaims, "The quality goes in before the name goes on." Patient records, over which we slave, document the quality of our care; I want them to be clear and accurate before I let some computer sign my name on the bottom line. But hey, don’t shoot me – I’m just the scribe.
This column, "Inside Rheum," regularly appears in Rheumatology News, an Elsevier publication. Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. You may reach him at rhnews@elsevier.com.