Old timey records were made to summarize the doctor’s thinking at the time of a visit and a note of the plan.

Then medicolegal necessity required longer and more complete documentation, something that would stand up in a courtroom as a demonstration of a rational and reasonably complete clinical assessment and treatment paln.

Now we are in the age of the EMR and the driving force behind the grotesquely overwording is the CPT guideline for Evaluation and Management coding. EMRs aren’t about making records that make sense for some other doctor, or about establishing useful databases for remote access or to create a comprehensive patient record to avoid unnecessary over-testing or drug interactions. They are made to create records that will pass Medicare audits.

All you have to do is follow the money.

As a primary care doctor, I get them back on patients from an increasing number of consultants (and they are all using the same system, so, at a glance I can’t even tell if it’s an ENT or a neurology note). Often, I can’t even figure out the diagnosis, let alone what they REALLY found on the exam and whether the history was similar to what the patient told me in the first place.

Sadly, we’re about to go to EMR because the documentation requirements for reimbursement are nearly impossible to achieve by any other means.

It’s similar to the subtle downfall of “progress notes” which went from communication tools among physicians caring for a patient to CYA records and documentation for reimbursement purposes.

Attack of the clones: “What I see constantly when I receive EMR records from other practices (where the patient was first treated elsewhere and the treatments were not successful so they are now coming to me) is that the patients look identical. That…