Physicians must reclaim the medical record

acp new logoA guest column by the American College of Physicians, exclusive to KevinMD.com.

I recently saw a new patient who came to our practice following a lengthy hospitalization. He is in his 80s with a fairly complex medical history typical of many in this age range. Yet, after carefully sifting through my first introduction to this gentleman — a 32-page discharge summary — I was completely unable to glean the circumstances that led to his hospitalization.

Amid the completed tick boxes, auto-populated forms, a recurring list of medical problems, and a printout of every medical and nursing order written and medication administered during his hospital stay, every few pages I found a couple of sentences of text that were clearly propagated from previous entries with either very minor or no changes whatsoever.

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