I’m used to typing my medical records notes myself. Probably because I’m a pretty good touch typist, but there are other reasons, too. For one, I’m not used to dictating into a machine. It simply feels unnatural to me. It’s like having a stenographer on your lap, but without the advantages.
Another reason is that I like to go back and forth and fill in the blanks as I interview the patient or do my clinical examination. So I prepare the record while the patient is present and I can’t imagine dictating while the patient listens in on what I say, so I’d be very constrained in what I could dictate. Like: “The pain story the patient presents seems unusual. Could this be an insurance neurosis?”, then turn to the patient and ask “exactly how often does that leg of yours hurt?”. Seems kinda weird to me. Dictation would force me to let the patient go before I organize my thoughts and dictate, and any extra information I discover a need for will remain lacking, since I can’t ask the patient for it. He just left, remember?
Yet another reason is that I don’t think I’d dictate much faster than I type, so having a secretary type out my dictation and then have me approve it seems such an incredible waste of effort. On top of that, the secretaries at the place I work right now are about ten days behind on dictation, so checking and approving dictation notes that are two weeks old is yet one more problem. I simply would be unable to tell if they had missed anything in the transcription or not.
While the dictation tapes are awaiting transcription, the notes aren’t available in the record systems, often hindering follow-up of the patient as well.
Actually, I see not a single advantage to the dictation system except for keyboard-challenged physicians. Happily, the new generation of physicians are bound to be much more keyboard savvy than the last, so there is hope.
Except for one thing… the medical records systems are often based on the presumption of dictation followed by transcription, making it fairly difficult for a physician to enter his own notes. How’s that?
Well, in the package I’m working with, for example, it’s very difficult to look up information while typing, since a secretary typing while listening to a tape very rarely needs to look up anything.
If you’re entering notes into the daily records yourself, you can’t look up previous notes. You can pop up a special window to find lab results, consultant’s notes, and similar, but all in a very flat and unorganized manner, since so few use that function. While typing referrals to other specialists, you can get at daily notes, lab, diagnoses, etc, but not at previous referrals or their responses, believe it or not. So if you need any of that information, you have to quit what you’re typing, not being able to even save it as a draft, go to that other document, copy the relevant text to the clipboard, then start your document anew and paste the text you were looking for. If you need more than one block of text, you’re SOL. For more complicated documents, I usually print out the most relevant referrals and notes first, then type while having them available on my desk, so I can copy the relevant passages. It’s an insane use of a computerized system, but there you are.
I’m sure the next generation of physicians, the ones brought up with computers, will be very frustrated by this kind of thing. I know I am.