Two of the first things all medical students are taught are how to take a proper medical history, and how to write it up. These are skills that, when refined, form the basis of the art and science of medicine. Unless you can listen carefully to your patient and organize the information you’ve gathered, the correct diagnosis will likely elude you.

As a patient, you may have surmised that there must be such a thing as a medical history, because many doctors these days are fixated on their computers rather than on their patients during appointments. If you assumed that the purpose of all that keyboarding is to create or add to a medical history so that solid decisions can be made going forward, you’re right.

Well, almost right. There is a consequence to paying too much attention to the computer and not enough to the human being whose health is supposed to be represented there. It’s a sorry thing to see a life reduced to a series of drop-downs that correspond to insurance codes but that may not accurately represent the human in question. A medical history is supposed to help other medical professionals rapidly get up to speed on a patient when there’s a handoff in care — when going to see a specialist, for example. But the data dumps that most doctors are creating in lieu of proper medical histories mainly exist for the purpose of billing the insurance companies.

It’s a very different experience at the Sheldon Sowell Center, where appointments involve engaging, thorough conversations that are very much two-sided. With each appointment, your physician creates a note (in English, not drop-downs) that documents what you’ve told them, what their examination and lab studies show, what their interpretation of the findings is, and what they plan to do about it.

At our practice we also conduct in-depth annual health assessments. At these visits, we create a longer document that follows the same format but expands greatly on it to include your medications, surgeries, allergies, family history, health habits, significant studies such as cardiac treadmills and colonoscopies, and more.

Creating this document serves multiple purposes. By organizing your medical history, it relieves your doctor of having to depend on their memory for the myriads details of your health. It’s a chance to think through your care in an organized way — after all, committing something in writing requires discipline and careful thinking that casual discussion does not. And, when you see a specialist or are in the emergency department, it allows those caregivers to absorb all the essentials of your previous care in a matter of minutes.

It takes effort to create these medical histories, but as the saying goes, that’s why they call it work. And if you’re a doctor, this is literally your job. 

So why have medical histories fallen on hard times? The main culprit is the EMR — the electronic medical record. Because insurance reimbursement requires specific documentation for payment, the software that most practices use provides templates which allow efficient data entry at the expense of clarity. 

So, for example, instead of writing, “Mr. Smith is here today for an earache. He doesn’t have a cough, sore throat or runny nose,” the template likely produces something like, “Patient presents with earache. Denies cough. Denies sore throat. Denies runny nose.”

This produces notes that are limited by the template chosen. It’s part of the reason why, if your appointment is for a sore throat and you mention a rash, many doctors will stop you right there and require you make a separate appointment to talk about the rash. The sore throat template has no questions about rashes, so a new complaint requires a new template and thus a new appointment.

It gets worse. Because information is so easy to enter into a template, misinformation is, too, making template-driven notes subject to horrendous errors. We’ve seen notes where, for example, the uterus is carefully described as being normal … in a woman whose uterus had been surgically removed.

We’re not Luddites at the Sheldon Sowell Center for Health. In fact, we take quality software so seriously that we write our own. But we gather information the only way that works: by listening patiently, asking careful questions, then writing coherent medical notes that are intended to summarize, clarify, and explain — for our patients and the specialists to whom we refer them.

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The information posted on this blog and website are for general information only and should never be relied on as specific medical advice for an individual reader.  No financial relationship exists between us and any recommended products or persons mentioned. All material contained here is the property of the Sheldon Sowell Center for Health, PC, and cannot be copied, reprinted, or linked to without our express permission.