Tuesday, March 25, 2008

It's a Wonder They Haven't Killed Us All



The present state of most medical records is a disaster. Doctors can operate on a patient who is physically thousands of miles away via a computer and a remote robot, but when you are sitting right there in front of them they look bewildered when you bring up something you discussed with them just the week before.

I was at the Dentist office yesterday and he asked about a tooth that is showing some signs that a filling may be necessary. I had to tell him that he had done a glass ionomer filling on that tooth two years previous and I suspected that there was some micro leakage on the lingual/distal edge. He was surprised I knew my filling locations.

Now I don’t expect him to remember everything, however they keep an electronic chart on me along with a paper chart. Had the electronic chart been set up correctly he should have been able to look at the entire history of each tooth in my head. He should have been able to see a comparative historic periodontal charting. He should have been able to flip through a historic progression of the several radiographs I’ve had of that tooth over the years. But no, each time I go in there it is like I’m there for the first time.

Sometimes the staff shuffles through my records that have been layered in my chart over the last 15 years. Eventually I ask what event they are looking for and then I’ll give them the range of dates to look for or I’ll answer their question from my memory.

Charts are basically used to cover their asses in a law suit, but they could be so much more. Data bases are powerful programs that should be used to show progress in either direction.

The doctors we go to have no idea of what they prescribe to us. Every chart should have a sheet of medicines only. If you visit your physician for any reason, you should bring all your medications with you. Don’t forget all that non prescription stuff. Some of that may react with what you are already taking.

It will be so nice when we have a down load of our medical records to carry with us. That is if the data is organized and usable by others in the medical field. We really need to advocate for our selves and more importantly know our medical history. We need to act as though we are physicians who are hiring someone for a consultation on a complicated case. That case is our lives.

5 Comments:

Blogger Uncle Walt said...

I think it depends on the level of computerization the doctor had during medical school. I've found younger doctors tend to be more "computer literate" than older doctors. Older doctors tend to resist having to use computerized records.

With all the schooling they have to do, you'd think some of it would include computerization of medical records - but it doesn't. It's up to each doctor, or their employer, how much computerization to use. Thus the wide disparity between doctors' usage of computerized records.

7:55 AM  
Anonymous CB said...

I posted about how to keep a personal Medical journal last year, using online forms you can download and adapt for any medical concern you have. It includes a page for the current medicines you are on, along with the REASON you are taking that med (so many are taking a med for one of its side effects) and a page to download for you to have your doctor fill out if you have a special condition that needs specific attention. Most wouldn't believe the horror story of my dad's trip to St. Vincent's for treatment of his heart attack and they totally ignored his Parkinson's, "forgetting" to give him his Parkinson's meds on time, ignoring the FACT that his meds made him extremely sensitive to pain medication causing extreme hallucinations, etc... If we had had the document signed by a DOCTOR giving directions on how to treat a Parkinson's patient it would have saved so much stress. Here is my post on The Notebook. It contains the links to the pages you can consider to use in your own notebook.

10:14 AM  
Anonymous Anonymous said...

PS> Hard copy is best for those trips to the ER, so make copies of everything. An electronic copy would never catch up, especially if you are hopping from hospital to hospital. ~ cb

10:16 AM  
Blogger Mike S said...

I have a Dr who uses electronic records backed up by a security company in addition to her own back-up. The VA also has all my stuff on computer now too. It's unbelievably quick and even works well in ER situations. I've twice needed to use an ER since they started it, once in Nova Scotia and once in Arlington, VA. Both times they had my entire history in hand in less than 15 minutes after I gave them the access info and they sent the request. As my records are with Drs in Maine I thought it rather efficient. The nicest thing is that all my DRs AND Pharmacists use electronic records and when one makes a change, it automatically infos all on the 'record copy to' list. Dentist and Optometrist and Onconogist are even on there. Best service I've ever had in the past 4-5 years:):):):)

12:05 PM  
Blogger The Guy Who Writes This said...

They have a long way to go out here before anything starts to even look seamless.

5:28 AM  

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