Many people view all the additional documentation required in today’s American medical facilities as cumbersome and even detrimental to the treatment process. After all, if filling out an Electronic Health Record can take up to 40% of a patient’s visit with a medical practitioner—or, simply cause the practitioner to put in very late hours after closing in order to catch up on paperwork—then it feels like the only people who benefit from these big pile of information are the facility financial departments and the insurance companies.
But the truth of the matter is, as with libraries, or any kind of archive, detailed information is detailed information, and there’s always very real chance that it will come in extremely useful in the future. The goal of an EHR is to provide a thorough, always accessible history of a patient, listing his or her conditions, consultations and treatments, so that any doctor or nurse practitioner needing important information about that patient can find it, and “pay it forward” by continuing to add to the file.
And sometimes this information because critical not just for medical causes, but for reasons of law. There have been actual legal cases where medical documentation has been vital in bringing justice to the victimized. One case involved a doctor who treated a woman for the injuries she sustained at the hands of her partner. The doctor worked in concert with a medical scribe to meticulously note the location and extent of her injuries. When the time came for the partner to be charged and prosecuted in court, the doctor played a role in bringing the accused to justice, but it required him to present his professional opinion of the woman’s injuries as evidence in court.
Of course, by the time the court case arrived, a lot of time had passed, and the doctor had treated many patients. He couldn’t possibly be expected to remember every single nuance of the woman’s injuries during that incident. Instead he relied on the thorough documentation of the exam, which was presented to the court, and it was because of this that a conviction was possible. If the same doctor had only been able to say “I think it was pretty bad, but I can’t remember how or why with any certainty,” that would have made for a poor showing in court.
Accuracy in medical records can be tedious. But it can also make a real difference in the most surprising of ways.