Skip to main content

Your Chart: Do you know what's in there?

This is a wonderful post over at The New Life of e-Patient Dave's website about electronic health records. I strongly encourage patients and clinicians to read it. While there has been much debate about whether EHRs actually improve patient care and save money (I believe they will do both) the move to electronic records will enable transparency when it comes to viewing and reviewing your own chart.

Have you ever tried to get a copy of your own record? It is not exactly the easiest process. Most providers offices require you to complete a records release form which is filled with legal jargon and makes you seriously question if you really want to get these records in the first place. Some providers charge you per page to photocopy your record and good luck in thinking that this will be processed promptly by the staff. Once you get your hands on a traditional paper chart copy, it is nearly impossible to decipher. Is this acceptable? Maybe accessing your health record should be like getting your credit report. I know that in a matter of seconds I can log on to one of the credit reporting websites, enter some information and have complete access to my full credit report.

So now that you have access to your chart, I am reminded by the Seinfeld episode, "The Package" where Elaine has a rash and sees a few doctors only to be shunned by what is written in her chart:



Should patients have the right to question what's in the chart or make their own comments? Can subjective data be debated? Would clinicians document differently if they knew that patients had unfettered access to what's in there? Is our system of charting archaic and does it truly capture the essence of the visit? Could we be making better use of technology and snap digital photos of certain conditions and attach them electronically to the record? If we are to be patient-centric, how much input should patients have in their records? Would clinicians have to "defend" their charting if questioned? These are many questions that could make for some interesting debate. What do you think?

I think we have a long way to go when it comes to transitioning to electronic records. Yet, the time has come. We need to stop talking about it and thoughtfully start implementing it. It all goes back to communication and understanding about disease processes and steps that can be taken to improve health. After all isn't your health record just as important as your credit score?

Comments

Great post! Very good points, I will share this with my facebook friends.I am adding you to my blogroll, I found your blog through npbo. Will keep up with your posts as a fellow NP.
Jennifer Butler,FNP
www.np-viewsandnews.com
Anonymous said…
SF...you will be happy to know Carolyn was in last week to train us on our new EHR...yes we are going to electronic records..lots of work ahead with the usual suspects..(per-diem stuck in the past) but I am committed...waited a long time to get here...so excited!!!!

Popular posts from this blog

Private Practice

There is an interesting trend that I'm observing and don't necessarily see how this is going to turn out. I'm seeing more and more nurse practitioner's opening their own autonomous practices. Many of these offices set out to offer care that is personalized, covered under insurance, and of course high-quality. I'm also seeing more NP specialty/sub-specialty practices such as house calls, incontinence, and women's health. This is in a time when more physician practices are joining together in these conglomerations that aren't necessarily tied to hospitals. You'd be hard pressed to find a solo primary care physician these days yet nurse practitioner solo practices are popping up. The talk about the formation of accountable care organizations can be attributed to health care reform and the spurring of large multi-physician practices. What to make of this? I honestly don't know. Many people and patients have said to me "you should start your own prac

NP Residency

The healthcare system of today is so complex yet so dysfunctional that I believe the time has come to educate and train the NP providers of tomorrow in a way that is reflective of that complexity. We have done a good job up to this point but need to bring that to the next level. Residency. I'm not necessarily referring to the typical residency training of physicians which takes place in hospitals but a residency-type of program in an out-patient setting (ironic that we use the term residency). We realize that healthcare is not exclusively delivered in hospitals. It takes place in independent providers offices, in community health centers, in mobile health vans, and in retail settings. It takes place in people's homes and places of employment. It takes place in many of the health decisions that we make on a daily basis. I found this NP residency program in Connecticut that claims to be the first NP residency in the US. The programs admits 4 NPs each year and trains them to ha

Repost: Let Us Be Heard

I started this blog, A Nurse Practitioner’s View, 3 years ago because there were very few health stories that even mentioned nurse practitioners as part of the health care landscape. Right before I started the blog, I would respond to other health policy articles published on the Web by writing comments to the websites – only to be subjected to baseless and factually incorrect statements. It was soon thereafter that I decided I would write my own perspective on health policy, trends, and news. I also felt it important from a credibility aspect to not blog anonymously but to put my name on it. I recall those few early blog posts that I proudly wrote and would feverishly check my blog visitor stats to see if people were reading. Well, it was a bit slow going in the beginning with about 10 – 15 readers but as they say, “if you build it, they will come.” Today, the blog enjoys hundreds of visits a day, has a Facebook following, has enabled me to be “discovered” to blog at  Online Nurse