anyone here living w an ostomy?

[3catwoman3]

22. The biggest problem I saw in EHR besides the aforementioned...

...amount of time spent on documentation were built-in inaccuracies.

1. Many/most of the preloaded templates contain the phrase "Medical, surgical, family and social history reviewed and updated today." Insurance requires that you do that every visit, even if you last saw the patient just yesterday. Then, when you go to those individual sections of the record where the clinician should have entered relevant details of all these histories, there's not a damn thing in there and it says " History never reviewed." Did you do it, or didn't you? Mutually exclusive. People are pointing and clicking without reading everything in the template.

2. Preloaded physical exam descriptions that contain things that I know the clinician did not do. Worst example of this was a write-up of a visit for strep throat that contained a full neurological exam, including all the cranial nerves, balance, coordination, reflexes, and fine and gross motor testing, as well as as a head-to-toe dermatologic assessment, including the skin of the genital area. Nobody, and I mean nobody, routinely does a full neuro exam and looks at the genitalia for a strep throat visit unless someone has unusual neurological complaints or says they have a rash "down there" - both are possible, but extremely uncommon. If I did not do something, I didn't want a template designed by someone else saying that I did.

Tracking lab results, and being able to send prescriptions electronically are handy features. That said, there is one built-in potential error with antibiotic prescriptions. Antibiotics work best given at precise intervals in order to keep a steady level of the drug in the blood stream. That means a twice-a-day antibiotic should be taken at 12 hour intervals, like 8A and 8P, and a three-times-a-day one at 8 hour intervals, like 7A-3P-11P, or 8A-4P-12MN.

The preloaded instructions on the EHR only said "twice a day" or "three times a day." So, a patient could very likely end up taking their twice-a-day antibiotic at 10 AM and 6 PM, which would leave them with an inadequate blood level for 4 hours between 6A and 10A, and a suboptimal effect on the bacteria the antibiotic is supposed to be killing. I would take the extra time to change the dosing instructions to what they should have been, but I know many clinicians did not.

I was uncompromisingly fanatic about thoroughness and accuracy in my documentation.