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How to get a perfect chart out of a medical appointment

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Fred N. Pelzman, M.D., a New York primary-care physician, writes (amusingly) in Med Page Today about how “I made patient’s chart perfect.”

Among his remarks:

“Despite doing nothing, we were as updated as he was going to get.”

“Now, none of {the patient’s} refusals {to address various medical issues/opportunities} are permanent; the next time he comes in the EHR likely will flag me again, highlighting things I need to ask him. If I want, I can make them permanently silent, but I always think it is worth leaving them as fluid, so that I can try once again the next time he comes in.”

“None of this documentation and charting made my medical record for him a better true record of the care I provided that day. While, in fact, in the assessment and plan I describe how I tried to encourage him and explain to him why many of these items were probably good for him in his terms of his long-term health, the clicked boxes that gave me a clean healthcare maintenance field in the electronic health record really didn’t leave much of a trail for another provider to follow.”

He concludes:

“If we work towards a better more interactive more cooperative electronic health record, utilizing the entire team, and our patients as well, then maybe all our charts will end up being nicely tucked away, everything clean and clicked and ready to rock our patients to better health.”

To read Dr. Pelzman’s piece, please hit this link.

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