Chartomegaly

The suffix "megaly" means large; cardiomegaly is a large heart, hepatomegaly is a large liver, even acromegaly means large digits. Chartomegaly means someone's chart is out of control. Unfortunately, I think with medical records, everyone is starting to get chartomegaly. It bothers me that now with functions such as copy and paste or printing pre-determined phrases, the majority of a medical record is completely useless. For example, before every anesthetic, I click a button that creates a note that says "The patient's history and physical were reviewed and the patient's condition is appropriate for anesthesia. Please see anesthesia pre-op note for full details." This is a completely useless note and creates unnecessary clutter in the chart. Indeed, patients who go to the emergency department can have dozens of separate nursing notes that say things like, "Consultant at bedside" or "Assisted patient to bathroom." While perhaps somewhere there is legal or financial reasons to keep such information, it dilutes the chart down so that we cannot find what we're looking for.

With paper records, we lamented that we could not find old documents when we needed them. Things have not changed with the electronic record. There is great faith in the electronic medical record by the government and those who champion systems solutions, but in my mind there is a long way to go before useful, manageable, efficient, and informative charts are in place.