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Comment by classichasclass | Hacker News Reader

I have a rule I don't do charting in front of patients. Maybe I'm old-fashioned, but I think it's rude. I might take a couple notes for later, but I do my charts in my office. I have never logged into an EHR in the exam room.

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That seems silly. I would WANT my doctor to be looking at Epic while seeing me to have the best data.

You maybe. Most other people indeed take it as a sign of failure or lack of manners. Healthcare is social first, logic second (or third, or maybe fourth...)

So you double the work by first writing down data and then copying it into EMR? That is insane.

you must print out old notes and test then and carry them into the room like you're pretending it's still in the paper chart days

which is fine until something comes up that you didn't anticipate and print out. Then you can a) fake it, end the visit and follow up with pt later after you've looked it up or b) log in and get the info

How do you have the pt's current med list? Does staff print it out after they've roomed the pt?

Also, how are you ordering test/procedure? Writing it down for staff to do later? Violates most org's "CPOE" policies. Otherwise pt leaves and your staff has to call to schedule later, including labs that maybe they could do before they leave.

You must have re-created a paper chart workflow in an EHR era which is only possible if your staff/org enables this for you

Most of us are just employed widgets in the health care factory, and don't have the pull to get staff to work with this kind of workflow

I read the chart before I come in and get it fresh in my mind, and I do my orders immediately after I've seen them. This is Epic, so that tends to merge with the workflow, since it really wants you to do your documentation after you've done everything anyway.

At least for the health maintenance stuff, I already know what needs to be done on that score before I even enter the room. If I have to grab something out of the record, like a result I wasn't expecting, I can quickly run back to the office (it's just around the corner) and come back.

So, no, no paper.

I guess you're smarter than I am

I can't remember all the details to a sufficient level that I feel comfortable that I'm not forgetting something

and how do you know the current vitals and medication list? When the pt tells you they saw Dr X for Y (that you didn't know about) do you not want to look at that in case it impacts your plan? I guess you go out and come back? If you rx a med that needs lab monitoring, did you memorize that too? What about trends in labs?

IDK, I need info while I'm seeing the pt

If the vitals were fine, as far as I'm concerned I don't need to remember the exact number (even though if pressed I probably could), and the same for labs. If a patient wants the exact values we'll make a copy for them.

For the med list, I do know what they're taking, but my usual folks bring in their pill bottles anyway just so we can make sure they all match up. This is also useful because if I want them to discontinue something or change it, I'll write it on the bottle, and make the change in the MAR when we're done. We're not usually making massive med changes on any one visit.

If they saw someone in the interim, I'll have already seen it in the chart before I see them, and if it's not there, I'd have to order the record anyway so it doesn't matter. Most of the offices here are on Epic, so Care Everywhere will usually get their notes.

I think we just have different practice styles here.

This very much reads like the arrogance that people complain about doctors having which makes them really not like doctors. When a server doesn't write down people's orders and gets something wrong, it's pretty trivial compared to when a doctor's arrogance thinking they remember all of the details and get something wrong. Even if you do "go back to the office right around the corner", you just come across as checked out and "too busy" to come prepared. Either way, again, this reads as the embodiment of everything that people hate about modern medicine, especially in the US.

There's no ideal solution: either you check the file in front of the patient and many find this impolite or a sign of failure to know everything, or you don't check and many find you're sometimes over assertive and likely wrong... As in many jobs, you can't please everyone.

Honestly, the real mystery is how can GP handle the workload with this completely sequential workflow. I'd just die of karoshi and sleep at work every night if I did that. GP must be ultra efficient.

might be able to incorporate an ambient AI scribe into this flow pretty well, plenty of docs are seeing success with that.

There are a couple of SaaS products in Australia that do examination transcription.

I know of one practice that went all-in on the stuff. They had to re-hire their secretaries after their AI transcription recorded "this bone normal, no damage to this other area" but totally failed to mention that the first part of the sentence was "distal fracture to whatever", ultimately failing at it's most basic bloody function.

I'm pretty sure the founders are not doctors but tech industry types, who figured that there was some non-zero error rate and just like, collectively shrugged at the consequences.

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