USD Sign in to Purchase Instantly. Temporarily Out of Stock Online Please check back later for updated availability. Overview This book takes a problem-oriented approach to the evaluation of common symptoms presenting to medical students. Average Review. Write a Review.
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The text covers servomechanisms, hydraulics, thermal control, mechanical systems, and electric circuits. And Larry Weed was right: we must have a structure to record what is happening to our patients, and his problem-oriented approach remains the most appealing one. Ultimately, one wonders whether natural language processing will make such a structure less important, in the same way that I no longer pay much attention to filing documents on my Mac now that its search function is so powerful.
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They are also cognitive forcing functions , ever-so-subtly modifying our approach and language into something that can either improve our clinical care and teaching, or not. You can usefully weave together a problem list in the assessment part of the note, though. We have Epic, too.
What I do to ameliorate the issue you describe is that I never, ever use smart text. I think smart text can kill people. Importing gobs of undigested lab results and such satisfies the billing coders but, as you point out, makes it very difficult for somebody reading the chart to figure out what is going on with the patient — better? That is brilliant, Dr. Our system just got Epic and I am struggling to figure out a way to preserve my clinical reasoning and what I think was quality documentation in a post-Epic world. Pathologists encounter the same problem in pathology reports, where the free text comment used to be the place where we explained and synthesized the diagnosis, or expressed our degree of certainty, or raised the possibility of other diagnoses.
Somewhere in the vast EMR world there must remain room for free text, or indeed doctors as well as patients can be reduced to algorithms. Robots, anyone? I can see how the problem-based charting approach would naturally work against the goal of integrating multiple problems on a patient. One can easily envision the Problem List becoming a repository for all of the requested medical terms that our clinical documentation improvement teams recommend we add to the record. At the APDIM national meeting this year, the folks from the University of Pittsburgh held a fantastic breakout session where the topic of discussion was the quality and content of progress notes.
Their examples were from an electronic medical record, and were passed around to 40 or so faculty in the room. What struck me was the utter lack of consensus about many of the core questions regarding progress notes: should the medication list be included? Should it be problem-based or system-based? Not even agreement on this last one. One point that was seen very favorably in this breakout session was the idea you describe — a dedicated field for the brief summary of the hospital course thus far.
We will be embarking on attempting to build this prompt into our progress note templates, although having been live in the inpatient setting for 18 months now, I suspect that habits will be that much harder to break. This is probably the most lucid exposition of the shortcomings of the EMR available. While the EMR depicted in this post is Epic, in defense of Epic I would like to state that it is the best of the many available.
Unfortunately there is little impetus to audit the quality and accuracy of notes in electronic records. There is no financial gain from such tasks. Rather, the audit functions are geared towards the billing component as organizations attempt to game insurers while avoiding fraud and abuse.
Documentation specialists and audit consultants who now make handsome rewards are little interested in the concerns you voice. Templates and drop down menus only enhance often inaccuracies from earlier notes or clinical examinations never conducted but recorded by a click on the enter button by the in attentive user. These inaccuracies can become patient safety problems. The EMR which yet has great potential must have safeguards placed on its use to prevent it from becoming a tool for harm and scoundrels. Bob, as usual, you have penetrated to the heart of the issue…maybe… All above reasoning and comments indicate that the note is intended to communicate to subsequent care-givers, and of course, subsequent lawyers.
Is it? Briefly: all decision makers, including family, MUST be present for the bedside conference. Note the similarity to airline briefings, football huddles, quality circles. Make no mistake, this model is NOT a case conference. It is decision making in real time, for the next relevant period, typically a day. In medicine SA is dismal, because SA is established by the mission plan briefing…absent in medicine. The unintended consequence of Collaborative Rounds is…far fewer calls from concerned family.
After all, they were there, and contributed! Later, a scribe can write the legalisms orders and SOAP note, or better yet, continuous graph, for lesser interested parties. Everybody has already heard and scribbled down the decisions orders. Have you tried this at UCSF? As a health plan medical director in caring out my oversight functions, especially in the quality management area, the electronic medical record produces ream of disconnected clinical visits by multiple health care providers. Not to mention, that the ideal note will need to be succinct and be generated efficiently quickly enough so as not to consume hours in an already busy day!
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And where are we supposed to put our differential diagnosis?! Possibly the most valuable segment of our clinical reasoning, in my opinion—and definitely the most valuable section for educating students and residents—has NO place that I have found in most EMRs. You are finally beginning to recognize the adverse impact the device has on your cognition, yet you trivialize it and the adverse events from the device.
The EHR is destroying the creativity of doctors needed for integration and diagnosis by eliminating the interaction of the hand, the eyes and the mind. Is that a euphemism for death causing adversity? Bob, does your esteemed new Epic EHR have a search function, or are you scrolling and scanning to find historical information? I agree with the previous writers.
Bob gets right to the tragedy of fragmentation and isolation so often facilitated by HIT. If medicine could be mechanically summed up as the collection of organs, lab reports, vitals, etc, we would not need physicians. We could and perhaps should use technicians for that.
In real life, doctors swim in a sea of ambiguity, unknowns by them and unknowns as yet by medicine in general. Anything that further fragments the needed information, or suggests certainty when none is there, is dangerous…even if that information is instant and legible. Here, here to both Dr. Wachter and Dr. In my and Dr. Thank you! The issues you relate are quite pertinent. In fact, those terms are, I believe, an anachronism. These are no longer innocuous filing systems. What is being installed at UCSF and elsewhere are, in reality, enterprise clinical resource management and workflow control systems.
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How would the dockets read? Little seems to have changed since The health IT industry seems incurably autocratic if not autistic. My question is: how can physicians change this? Health IT improvements involving major informational capture, analysis and presentation enhancements let alone anything else are not inexpensive, and will cause damage to the bottom line in a highly competitive marketplace.
The perfect storm in health care is upon us- increase Diversity,, Complexity and Uncertainty. Medicine is a Art and a Science directed by mere mortals.
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The excessive over balance on EMR destroys the Art of Medicine, limits necessary creativity and innovation.
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