The electronic medical record (emr) is a powerful tool.  It’s great for compiling and storing information; and another huge perk is that provider notes are now legible!  The irony is that just because notes are now legible, doesn’t mean they are true.

Typical provider notes in the emr are very one sided- they represent what the provider is thinking.   But you don’t necessarily know the patient’s side of things.  This is not to imply that providers are typing incorrect information into the record.  But as the reader, you don’t truly know what the patient was actually told, or what the patient heard, or what the patient understood.  And this can be critical.

We all review the medical record prior to seeing patients.  And because we don’t fully realize that  ‘the emr is not always right’, many providers start their conversations by continuing where the record makes it sound like the patient is.  But particularly when first meeting a new patient, I caution you against this.

Mr RW, 60 yrs old, has multiple medical issues including:  advanced diastolic heart failure, atrial fibrillation, diabetes, and progressive chronic kidney disease.  On hospital admission, his creatinine was found to have significantly worsened, so the concern was that he would need to start dialysis sooner than anticipated.   He initially wanted nothing to do with dialysis, but after our discussion, he had changed his mind.  Mr RW realized there was still much he wanted to do in his life; he clearly wasn’t ready to die.  The cardiologist who evaluated him as part of the pre-operative evaluation prior to fistula creation left an ominous note in the emr.  The final sentence read in part:    “…high risk patient, for high risk procedure…”.

When I visited Mr RW the next day (and I reviewed the record so saw this note), I inquired about what the cardiologist had told them.  I could hear the relief in their voices as both he and his wife said they were told his ‘heart is strong’ and there’s ‘no problems’ going forward with the operation.

?!?!?!?!?

Would love to have heard that conversation.

So you never know where you will find your patient in terms of their understanding of ongoing medical issues.  And it’s why there will be upcoming posts about an important corollary, that being the importance of ‘the patient talks first’.  But for this post- the underlying theme is ‘the emr is not always right’.  As previously stated, you never know what the patient was actually told, what the patient heard, or what they understood.  And this is critical.