Monday, September 28, 2020

Pet peeves

Electronic medical records are great! They make billing so easy! All that information at your fingertips! But what if it's bad information?

Disorganized info in the EMR is a pet peeve of mine. One patient's Past Medical History was listed as the following:
Abdominal hernia
Esophageal Reflux
Hiatal Hernia
Irregular menstrual cycle
Migraine
Migraine
NO SIGNIFICANT MEDICAL HISTORY [all caps in original]
Unspecified disorder of skin and subcutaneous tissue
Varicose veins of lower extremities with complications

That's a lot of diagnoses to have "no significant medical history," even if "migraine" is listed twice. The varicose veins have complications, so the patient probably found those "significant." There is an old or external medical record that, when it interfaces with ours, generates diagnoses such as "unspecified disorder of the ...," and I honestly rather nothing were listed, as it conveys no useful information.


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