On Mon, Sep 19, 2005 at 08:07:46AM +1000, Richard wrote:

> I take in all you say. You must be fairly unique amongst doctors Karsten
I cannot imagine a responsible doctor to not want to have
structured data in the record (careful phrasing here). Maybe
I just have to properly order/structure my notes so I can
make up for the lack of quality of care that I deliver (just
musing).

> or perhaps it is the german system,
Definitely not. There is not any time during med school
where we even hear about the fact that notes *could* be
structured.

> or the sort of clinic you work in.
No, there's another doctor at that clinic who hardly
captures much of anything (good for me so I can re-delegate
all the paperwork on his patients to him ;-)

> Reason: I've perused many many thousands of clinical records from patients 
> from many hundreds of doctors in my time, and it exceptionally rare to find 
> structured notes.
Same here. Other clinics, other doctors, other mores.

> In my 'on-the-ground' tutoring of GP's in the use of clinical record 
> programs, 
> and in projects where we wrote the software specifically to enforce entering 
> a reason for encounter (for research projects), we had a huge problem trying 
> to educate doctors how to use that, and also if they knew how, getting them 
> to fill it in.
That doesn't mean we have to write crap software.

Karsten
-- 
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