My frustration continues to grow and grow with the more I work and work. I find it extraordinarily hard to believe that with all the great minds in computers and medicine, we don’t have a system that makes practicing medicine more quick and error proof. Even at the VA, a hospital system that has arguably the best computerized medical record, things ar incredibly inefficient.

An example of my day: get to the hospital, see my patients from the night before. Write down their labs from the computer onto a sheet of paper for my “progress note”–my assessment of what’s going on with them over the last day, if they have any new problems, and what I’m doing to diagnose and treat their problems. So I get their labs from the computer. Then I go to their chart, and write down their vital signs (temperature, blood pressure, pulse, breathing rate, O2 saturation) and Ins and Outs. Then I go to their nursing clipboard and write down their medications. Then I write out my assessment and plan for the patient (what I think each problem is caused by, and how I’m diagnosing/treating it).

Once this is all done, then I copy most of it to a little reference notecard, listing the patient’s recent labs, their ins and outs, and any changes or updates to their medications.

After all that, I present the patient to my attending, where I have to read aloud the vitals, the lab numbers, the changes in the lab numbers, any study results, and on, and on, and on.

An absolute, horrific disaster. A waste of time and paper.

I can imagine a system where we all have computers, or PDAs, and all our patients’ latest data just automatically appears. But it’s just a dream.

5 Comments »