Medical Documentation Is Becoming Cumbersome

The continued evolution of the EHR or Electronic Health Record, is a double edged sword.

On the one hand, there are the obvious technological benefits. An updated, always accessible health record for a patient can be invaluable. This is especially true if the patient has a substantial medical history that needs to be taken into consideration, but the doctor undertaking examination and treatment is new. In such cases, the EHR provides a valuable tool in helping doctors to make informed decisions about diagnosis and treatment, and, provided they update the patient’s EHR to reflect their own treatments, it continues a valuable chain of information that benefits both the patient and all future caregivers.

On the other hand, the ease and ubiquity of using an EHR rather than a traditional, physical filing system, has placed many unintended demands and functions on it that can complicate and even impede the elegance of its concept. Just because an EHR can hold more information and be easy to update, that does not necessarily mean even more information—some of it not even relevant—should be piled in and documented just because “there’s room for it now.”

And yet that is exactly what has been happening in recent years.

On top of the original concept of the EHR being a “living” constantly updated electronic document, groups beyond physicians have been taking advantage of the EHR’s digital format. In addition to simply documenting the current encounter with a patient, certain types of information must be included for the sake of regulatory compliance, or as a form of malpractice protection. In order for EHR forms to be approved for use in hospitals and clinics, certain administrative and regulatory requirements had to be observed. This means that for filing and organization purposes, information not necessarily relevant to a patient’s case had to be included for the sake of a patient’s data being correctly organized within a larger filing and database system. Because the government wanted to encourage the integration of the EHR, they introduced incentives for groups that adopted the system and used it in specific ways. In order to get those incentives, medical practitioners are encouraged to ensure that when the EHR is filled out for a patient, the incentive-required information is always included, even if, again, it’s not relevant to the visit at hand.

Another, perhaps more understandable factor that has complicated the usage of the EHR is the discovery that that these records can decrease the possibility of malpractice in a hospital or clinic. As a result of those findings, there has been a greater emphasis on including information in the EHR in the hopes of—if not reducing malpractice incidents—protecting against them, by showing all the documentation that proves the practitioners were conducting themselves a prudent, legal manner.

This is one of the reasons why a Medical Scribe can provide valuable assistance to any ED or clinic. Scribes from experienced companies like ProScribe take much of the burden for this record keeping and legal protection off the medical practitioners. Physicians should be treating patients, not making sure a facility has proper legal documentation prepared as a preventive to a lawsuit. Medical Scribes give physicians and nurse practitioners the time and flexibility to address the patient during a consultation. So even though the consultations may actually be shorter, there’s far more direct care and interaction, while the Scribe handles the critical documentation procedures so necessary to keep the administrative aspects of the facility running smoothly. 

Information in medicine is absolutely vital, but information should be handled by information specialists, while medicine is handled by the medical practitioners. The use of scribes facilitates a more balanced relationship between these two elements.