Your Doc's Case Notes
Many doctors are in the habit of dictating their notes after seeing each patients and then having the audio recordings transcribed. However a study by researchers at Brigham and Women's Hospital in Boston and published online in the Journal of the American Medical Informatics Association revealed that physicians who employed a method called "structured documentation" did a better job of capturing key information. They used templates divided into separate sections and filled in areas for topics such as history of present illness, review of systems, and family history. Another approach called "free-text notes" in which doctor's typed into a single window similar to a word-processing program was less effective.
A release about BWH quoted lead author Jeffrey Linder, MD, associate professor medicine at BWH and Harvard Medical School as saying, "Dictating may be easier for the doctor, but patients need to be careful. Doctors who dictate may not be paying as close attention to information and alerts in the electronic health record that are important for patient health."