Note-unworthy

A patient was determined to be brain-dead, meaning her brain had no activity. By law, the patient was now dead. The family decided to have her organs to be harvested for transplantation. An anesthesiologist was called in to evaluate the patient ahead of the organ harvesting.

I found this line in the anesthesiologist's write-up of that evaluation:

Risks and benefits of General and Regional Anesthesia discussed with patient.  Questions answered and patient wishes to proceed.

A brain-dead patient who talks? I'm sure.

There are major problems with the switch to electronic medical records. Because of onerous and shortsighted regulations by the government and private insurers, our notes have to be chock-full of useless documentation. Time constraints necessitate us to use pre-fabricated computer templates that automatically fill out lengthy portions of our notes. The doctor is supposed to go back and change the portions of the computer-generated note that are untrue or do not apply.

In reality, the notes are rarely checked carefully enough, and crazy things routinely slip into the notes (like brain-dead organ harvesting patients who ask questions about the anesthesia, or pediatric patients who are 133 years old). The notes also become so lengthy and unwieldy that they are difficult to read. After all, they are written more by computer than by man.

In attempting to document everything, we end up documenting nothing, because our clinical notes are becoming worthless. Thanks to the increasingly bureaucratic nature of medical practice, the accurate and thoughtful medical record is becoming a thing of the past.