Tuesday, July 22, 2008
Just Because It's Typed, It Doesn't Mean it's Readable
The electronic medical record system has made things much easier for the specialists in our group, who formerly made entire careers of complaining that they never got timely access to labs or legible consult requests on the patients who were sent to them. Now that all the docs in the group have access to the charts, if you have a question you can just dip into the chart and read the notes and labs. I have to admit that this is an improvement, as is the fact that all notes are now legible (because they are typed). One problem still remains, however: no one has yet been able to solve the odd lingo that doctors create for themselves while taking notes. Abbreviations save time and minimize typing but often are understandable only to the person who created them.
V. recently sent me a puzzling notation she'd picked up from the chart of a patient on whom she'd been consulting, wondering if I could decipher it. The notation in question read:
NF - a little fruit.
I'll spare you the speculation we went through on that one, until I finally realized that NF stood for "nonfasting" and "a little fruit" referred to what the patient had eaten that day. (If you're checking cholesterol and blood sugar, this could be quite relevant.) Once you figure it out it makes sense, but a better solution here would have been to use the QuickText application. This allows you to preprogram various abbreviations, so that if you typed .nf and hit the enter key you'd get "nonfasting" typed out as a full word.
But then we'd have missed all the fun of trying to figure it out.