Electronic Medical Records
No longer do I need to carry that tattered piece of paper in my wallet that lists my medications – you probably have one of those, too. It’s dog-eared, has multiple crossed out lines as my drugs have changed, and truthfully has not been updated in several months. Visit after visit during the pre-exam period with the nurse, I would be asked if anything had changed with my drugs. I would share my tattered list, struggle with my memory to see if there had been changes and then tuck that piece of paper away for the next time.
I don’t carry that outdated paper anymore because of electronic medical records, one of the best things going for me and my memory these days. During the preadmission screening for an outpatient procedure I had performed this week, the nurse on the other end of the telephone was able to see my pharmacy list and one-by-one we reviewed whether it was a medicine I still take. She also asked when my most recent EKG had been done and I told her it was sometime in the fall – it took her only a few moments to find it in the electronic records and that eliminated the need for me to come and have another one performed. The same went for the required blood work – my family doctor had me complete that within the past week and the results were also readily available. Not only did this save time, it also saved money for me and my insurance company.
It is great to have all of this information accessible and it is important as patients we review our record to verify what’s in it, and make sure it is accurate. A few years ago, I had been prescribed Cipro (a powerful antibiotic) for an infection – it made me feel miserable and I asked the doctor’s office to note this and not prescribe it for me again. The next time a provider accessed my medical record and began the review of my history, I was asked ‘so, you’re allergic to Cipro?’ Over and over for three-plus years I continue to tell everyone that I’m not allergic but I just don’t like the side effects.
The problem seems to be that once something is in our medical record, it is like Fort Knox and only deposits can be made – there is no withdrawing information from the record, even if it is wrong. If I am lucky, I can get it amended with a note such as ‘patient says she is not allergic to CIPRO,’ but it won’t remove it completely. It’s maddening because I want my EMR to be correct, but I still don’t ever want to take Cipro again.
My EMR also says I have Coronary Artery Disease (CAD) , thanks to a myocardial infarction (MI) in 2008, but I can’t get that corrected, either. The tests in the cath lab show I have less than 10% plaque buildup in my arteries, hence I don’t have CAD. My MI was caused by vasospasms, but if I end up in the emergency room with heart problems, they are going to immediately think blockages if they see my EMR.
While at the hospital for my latest procedure, the nurse was again reviewing my EMR including the standard list of what drugs I’m taking; surgical procedures of tonsillectomy, appendectomy and bunionectomy; and conditions of heart attack and multiple sclerosis.
Then the nurse pauses and reads to herself, looks at me as if I might be listed as having two heads, and then looks back at her monitor to read again. After a few moments of silence, she turns and asks if I can explain an entry in my medical record – at some time I have presented somewhere with ‘dizziness’ which isn’t unusual having Multiple Sclerosis, but it also lists giddiness as another of my symptoms. We had a good laugh about that entry and she said mine is the only chart she has ever seen with this medical problem of giddiness. To make it even clearer that it is a real entry in my EMR, she pointed out whoever included this information had used a semi-colon as part of the entry.
There is no date associated with my reported episode of giddiness nor is there a record as to who put this into my chart. I have no way of going back to the source and having that part of the record amended. I do not have pseudobulbar effect with my MS, either, where I might experience a wide range of inappropriate emotions. I promise, even though I try to maintain a pleasant demeanor at all times even in the ER, I have never been treated for giddiness. Now I know that I must not be so pleasant the next time I might need emergent care.
This is again another example that we need to know what is in our EMR, and in the future when my record is being accessed, I am aware I will have to handle these questions over and over –
Allergic to cipro? No, I’ll explain again.
Coronary Artery Disease ? No, I will explain that too.
Giddiness? To which I will most probably laugh, giving proof to that troubling symptom lingering in my EMR.
Wishing you well,