Patient Care From Both Sides Of The Chart

1.20.11 The difference between patient care and computer care


A reader emailed complaining about her recent hospital experience. She said, “The nurse spent so much time fussing with the fetal heart monitor and computer she ignored me. I wanted to get up and pee, but she insisted on monitoring me until she could chart the right stuff. My baby was fine. Why did she do that?”

She did that because a huge part of a nurse’s job is documenting that our patients are fine while they’re on our watch. Your nurse should have let you pee. But, we’re taught in fetal heart monitoring (which is notoriously inaccurate for predicting babies in trouble) classes that if you let a patient off the monitor before you have a reassuring strip, you’re liable. On the slim chance that something bad happened while you were up in the bathroom, a medical malpractice court might come down on your nurse so hard, it would make your head spin. Does that happen very often? No! Absolutely not! But that’s what being a nurse these days means. Chart it so you can defend it.

I was at a doctor’s appointment recently where I discussed my symptoms with the back of the doctor’s head. She nodded empathetically as she clicked away on her keyboard. This was a doctor I hadn’t met before, on-call for my usual physician. When she asked a question with her back still turned to me, I answered by saying, “are you talking to me or your computer?” She whipped around and said, “I’m just trying to make your electronic medical record (EMR) as accurate as possible.” She was oh-so-huffy with me until I said, “Uh-huh, I get it. As a nurse, I understand it’s hard to meet all the charting demands that go with your job, but as a patient, it’s hard to talk about important issues with someone who isn’t really focused on you.”

The doctor sighed and said, “I’m sorry, you’re right. I just got a talking to by my supervisor that I wasn’t documenting everything in the EMR and I’m trying to improve that, but not your expense.” She snapped her computer shut and gave me her full attention.

Don’t get me wrong; I think accurate charting is crucial. That’s how vital health information is passed between healthcare providers. But a lot of what we chart these days is unrelated to our patient’s real health issues. By trying to cover all the bases with EMR, we miss the bases that really matter. When my medical records go from one doctor to another, I’m flabbergasted by how much vital information they don’t have and how much trivial information they do have.

You wouldn’t believe the stuff we have to document to satisfy hospital, risk management and insurance protocols - countless questions and drop-down menu items that are entirely unrelated to our patient’s relevant obstetric experience. It’s endless, time consuming, distracting and often gets in the way of developing personal rapport and providing patient care.

There’s an article on NPR this week about how seeing doctor’s notes could help patient’s change their ways. Healthcare providers type stuff in the EMR we won’t necessarily say out loud to our patient. The article describes how a doctor might tell his patient to improve her diet and exercise, but chart that she’s obese. The question is: would the patient be more motivated if she read that the doctor called her obese? Doctors say if patients are going to read their notes, they might chart differently. Would they chart more accurately what their patient actually says and focus less on documenting what the EMR wants them to hear?

Nurses are expected to do real-time documentation. If we’re giving pain medication, we’re simultaneously hitting the keyboard to document pain scale, location, and description. If we’re getting a patient ready for her C-section, we’re also documenting page after page of pre-operative procedures. While it makes the computer very happy, it doesn’t necessarily do the patient any good and, in fact, often detracts from our ability to really be there for our patient. We’re excellent multi-taskers, but not always so hot at focusing on real priorities.

Why is the EMR so important? Because, it’s our best defense against malpractice claims and how we justify payment from insurance companies. It’s supposed to provide a template for good patient care, but frequently, it’s just a template for good computer care.

Is there any way out of EMR-centered patient care? Healthcare providers struggle with balancing charting and patient care. If we neglect the computer to be fully present for our patient, we get a “talking to” later because we didn’t listen with our hands on the keyboard. But some doctors are creating interesting solutions. One doctor I know hired a medical scribe who follows her from patient to patient and documents so the doctor can give her patient her full attention. It’s very old school, but from the patient’s side of the chart, very satisfying.

I’d love to hear from some of you about your charting experiences. Do you feel your doctor, midwife or nurse is taking better care of you or the computer?

Jeanne Faulkner, R.N., lives in Portland, Oregon with her husband and five children. Got a question for Jeanne? E-mail it to and it may be answered in a future blog post."¨

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