Cross-posted from the openehr-technical list: On Tue, 2003-05-06 at 03:39, Thomas Clark wrote: > The presumption that a Patient is 100% lucent in a stressful situation is > subject to debate, e.g., accidents, flu, labor and delivery. > > Retrieve the information from the Patient; analyze it; compare it with the > record, if available, but give it a proper weighing. Don't forget the > symptoms and the reasons the Patient ended up in the facility. > > It is an information retrieval/analysis/credibility/reliability problem. The > information needs to be sorted.
About a year ago a friend of mine suffered a myocardial infarct at the unexpectedly early age of 53. Thanks to very swift thrombolysis, he survived with virtually no ill effects. However, during his stay in hospital, he was amazed that he was asked the same basic set of questions over and over again by different people, despite them having his clinical record in front of them, with that information neatly recorded there by an intern. He found that surprising. When he related this to me, I expressed no surprise at all - one of the first things you learn as an intern working in a hospital is that you should never trust the accuracy or completeness of someone else's entry in a medical record. So wherever possible, you always check the facts. Later, doing general practice locums, the wisdom of that view was confirmed. But I learnt to rely on records made by colleagues whom I knew and trusted. Now, this is, I suspect, a rather common attitude, and is something which seems to have been rather glossed over in all the discussions and studies of the benefits of an EHR. There's no doubt that, eventually, medical culture would change sufficiently to trust what is in an EHR, but how long would that take? Has anyone systematically investigated this question? -- Tim C PGP/GnuPG Key 1024D/EAF993D0 available from keyservers everywhere or at http://members.optushome.com.au/tchur/pubkey.asc Key fingerprint = 8C22 BF76 33BA B3B5 1D5B EB37 7891 46A9 EAF9 93D0 -------------- next part -------------- A non-text attachment was scrubbed... Name: signature.asc Type: application/pgp-signature Size: 189 bytes Desc: This is a digitally signed message part URL: <http://lists.openehr.org/mailman/private/openehr-technical_lists.openehr.org/attachments/20030506/7acd3a45/attachment.asc>
