Patient-reported symptoms may be left out of the electronic medical records (EMRs)

[agate]

One complaint I've noticed cropping up repeatedly on message boards has been that doctors don't listen to their patients and that their medical records are inaccurate. It seems that there is evidence that symptoms reported by patients are being omitted from the electronic medical records, according to this article from the New England Journal of Medicine Journal Watch (January 27).

Patient-Reported Symptoms May Be Left Out of EMRs







By Amy Orciari Herman
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Patient-reported symptoms may fail to make it into a practice's electronic medical record (EMR), according to a study in JAMA Ophthalmology.
Roughly 160 patients waiting to be seen at an ophthalmology clinic completed an eye symptom questionnaire. After their visits, eye symptoms reported on the questionnaire were compared with those recorded in the EMR.
Overall, there was a high rate of discordance between patient-reported and clinician-recorded symptoms. In particular, reports of glare were discordant nearly half the time; in 90% of these instances, glare was present in the patient questionnaire and absent from the EMR. Similarly, reports of pain/discomfort and redness were discordant a quarter of the time; in roughly 75% of these, symptoms were noted in the questionnaire and absent from the EMR.





The authors conclude: "These results suggest that documentation of symptoms based on EMR data may not provide a comprehensive resource for clinical practice."

[Parsi]

I'm not surprised. However, I'm not sure that it's because the doc doesn't listen. It could be lost in the amount of recording a doc has to do in relation to the listening and treating.

[agate]

In a way it amounts to the same thing, though, doesn't it? A doctor is probably faced with a mountain of information about a patient--his/her own office notes, latest test results, old test results, history forwarded from other doctors, input from current doctors, and the patient's own reported symptoms, which may have been filled out on one of the forms doctors give you to fill out while you're waiting for your appointment. What information gets lost most often? The patient's reported symptoms.

But isn't that information important enough for the doctors to see to it that attention is given to it?

[Parsi]

I think doctors should have a recording device to review what the patient said so that they can enter relevant info into their reports. ;)

[Sunshine]

I believe EMR is a disaster, it has made practice cumbersome and it is increasing doc burnout. They spend less time with patient and more time with EMR.

I am all for just using EMR for diagnosis, med lists, and test results so other docs don't duplicate it. Then, the doc can keep his personal notes and patient complaints separate in a handwritten form for his own continuity of care.

[Sunshine]

I believe EMR is a disaster, it has made practice cumbersome and it is increasing doc burnout. They spend less time with patient and more time with EMR.

I am all for just using EMR for diagnosis, med lists, and test results so other docs don't duplicate it. Then, the doc can keep his personal notes and patient complaints separate in a handwritten form for his own continuity of care.

[agate]

Doctors I know seem to go directly to their recording machines right after seeing a patient. They dictate their findings and then the notes are printed up and put in the patient's chart. I have a feeling that handwritten notes are going out of style.

Parsi, if the doctor's office made a recording, that sounds like an ideal solution to a problem I've been hearing about: If a patient comes in with a recording device, the patient is supposed to ask the doctor's permission to record the conversation or at least to let the doctor know that it will be recorded, I think. But some patients come with concealed recording devices, and the doctors aren't happy about this.

It does seem unfair to me too. Having the doctor's office make the recording would solve that problem. At least if the patient wanted to make his/her own recording (in case the doctor's office edited parts of the recording), that would be less of a problem, seems to me.

[Sunshine]

If a patient mistrusts a doctor enough to make a secret recording in case the doctor alters the record, it seems to me that patient ought to find a doctor she or he can trust. Trust is the foundation of a patient doctor relationship. i wouldn't ever consent to being recorded by a patient. It alters the flow of the conversation, of the relationship, and puts a chill on what the doc might think and feel.