Electronic or Paper?

Electronic medical records can be terrific – until they are not.

Paper records are very low tech: paper and a black ballpoint pen. There’s actually a law about the pen but no requirement about the type of paper. Other paper rules: every page in the chart must have two identifiers (such as name and date of birth, or name and patient number) and each entry must be dated and signed. No need for power or an internet connection. We all have heard the negatives: difficult to read, often misplaced and impossible to share. The written information can be scanty and may appear to be written in code. Medication directions are still in Latin.

Electronic records need computers. No power, no chart. Computerized records are easy to read – at least the letters on the page are always legible. The notes are very complete since all background information is dragged in, no matter the relevance to the current problem. (Yup, parents are both still deceased). There are still lots of abbreviations, both standard and not. You won’t see the diagnosis “pneumonia” but rather CAD, PNA or 486.  There is so much information in the note that it can hard to discern the plan. Entries still need to be signed (a multi-step process). In theory, information can be shared.

Electronic records can vanish in an instant. I have seen it happen. Paper records endure. Paper can be salvaged if wet and fire is less likely than a computer glitch. It’s not difficult to locate a misplaced paper chart but can be impossible to recover lost computer data. And how much do we want shared, anyway?