Tuesday, November 6, 2007

I magically morphed back to highschool... seriously

I'm finally on an outpatient month, a local GYN clinic, which is awesome enough (if you didn't catch it, that was sarcasm in my writing). I don't want to complain TOO much because working 8am-5pm with no call and no weekends is just slightly more than amazing. After working 80 hours/week for a couple months, 50 hours is like a walk in the park. Ya'll have it easy thats all I'm going to say.

Back to the point. This clinic has an EMR (electronic medical record), which if you didn't know, is the direction all of medicine is heading. This particular EMR is bulky, cumbersome, and VERY time consuming. It takes me around 30-40 minutes to type a note for a routine annual exam, and I type pretty darn fast. Thats on top of the 45 minutes to do the annual exam! So after all the time I put into writing the note, what happens to it? The 'consultant,' ie nurse, reviews a printed version and suggests changes in a standard issue red pen. Then, of course, I have to go back the next day and put in those suggestions, which takes at least 20 minutes. Absurd! I'm back in highschool again! It feels like when you get your term paper back and it's covered in red ink. The only thing missing is the A- in the top right corner... ok ok, maybe B+.

Here are some stellar corrections:

My entry: "pt is sexually active with only men, 1 current partner."
Suggestion: "pt is sexually active with 1 male partner."

My entry: "pt denies F/S/C/dysuria"
Suggestion: "pt denies fevers, sweats, chills, dysuria"

I never knew my poor use of the english language was being graded on a medical document.