Does anyone else feel like a monkey?

[ActionFigure]

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does anyone else feel like a monkey with all the templates in the EMR? I don't do any thinking during the H&P. I just read off the computer and click

 

[hamstergang]

Well you could think during the H&P and be sure to gather enough info in the process to check off the boxes. There should be no need to let your documentation fully determine your interview.

 

[colbgw02]

I always thought it was so strange when the physician would not even look up from the computer screen when interviewing the patient. Not saying the OP does that, just that I've seen it done. A lot.

 

[DrSnips]

I always thought it was so strange when the physician would not even look up from the computer screen when interviewing the patient. Not saying the OP does that, just that I've seen it done. A lot.

Writing the H&P and reconciling orders as you interview the patient is such a huge time saver that it's hard to pass up, even if it does make you look kind of antisocial.

 

[colbgw02]

Writing the H&P and reconciling orders as you interview the patient is such a huge time saver that it's hard to pass up, even if it does make you look kind of antisocial.

No doubt. I'm not questioning its utility, just its decorum.

 

[Bacchus]

does anyone else feel like a monkey with all the templates in the EMR? I don't do any thinking during the H&P. I just read off the computer and click

We've been asked to free text the HPI, for now, into the EMR by our attendings. It makes me feel less robotic because I'm able to maintain a conversation with the patient while typing. I do my ROS, PE and A/P outside the room. It doesn't add too much more time. The ROS and PE is after the patient leaves because that's not necessary for the patient summary we give.

 

[armscrubs]

I understand the OP's feelings, as a PGY-1 internal med I feel exactly like an operator. The need for thinking is gradually being taken away from us.

 

[dragonfly99]

thanks for posting.
Sometimes I feel like that in clinic (as an attending). In general I avoid typing notes w/patient in the room. At least most of the note...but as a result I end up staying late at work most days. So there is no great solution to this. Just don't forget the patient in your rush to finish the documentation, and do a good job. It sounds like you are a conscientious doctor or you wouldn't even be worried about this.
I'm a little old (late 30's) so I remember when we didn't have typed EMR notes (just some computerized lab results and such). Back then I just got writer's cramp and had to stay up all night writing H and P's when I was a med student (remember writing an 8 page one on this lined paper we had, and then the attending gave me a crap grade b/c I didn't mention ulcerative colitis in the differential dx on a patient with NO diarrhea/loose BM's but frank blood coming from his rectum!).

Sometimes it feels like you can't win for losing...just do right by the patient and don't cut and paste stuff that is wrong/inaccurate, and you'll be doing better than some people.

As an aside, when I read referrals and some other doctors' notes, I feel like I'm looking at something a trained monkey wrote...LOL. Just because we CAN cut and paste and have all these templates, I don't think it absolves us from thinking and sometimes putting too much extra crap in the note just detracts from the actual useful information.

 

[nlax30]

We just moved to our full EMR with electronic notes and order entry.... I'm quickly finding out which attendings are horrible spellers, it's been amusing to say the least. I saw one note where everything was in caps except the first letter of each word....

 

[nlax30]

Overall in the hospital I think this will be a little quicker as before even though we dictated our H&Ps, we still had to have a handwritten form of some sort on the chart that took a little time to do. It's certainly made daily progress notes a little quicker since it carries over certain sections from the previous note and auto populates labs.

In clinic though I still struggle with a good workflow. If I'm typing up with the pt there in the room I feel bad, if not then I'm staying to finish notes.