The EMR Template: I Want To Believe
The X-Files fans will remember the poster that Agent Mulder had on his bulletin board with a picture of a flying saucer and the words, “I want to believe.” That’s how I feel reading EMR notes sometimes. I want to believe, but I doubt.
I know how this happens. The EMR vendor, the practice implementation team and the doctor have a meeting to develop the “normal” template for a hospital admission or a diabetes follow up visit. I myself may have participated in these meetings. Let’s use the admission as an example. We want to develop a template with a comprehensive exam, so that it will meet the requirements for a level two or three admissions. The coding specialist hastens to add that not all admissions are high level admissions, but if the admission is complex, we don’t want it to down code based on missing one exam element. The template is done, and the doctor never looks at again. The doctor never reads, line by line, the admission note that s/he generates using the “normal” exam template.