Epic

As my colleagues in the US get ready for the transition to a new electronic medical record system, I thought I would write about notes today. Here is an example of our charts (more on how we got that EKG later). They're basically just clipboards with a lot of papers stuffed into them. There is no logical order and pages are not numbered. Generally, there is a cover sheet with the list of diagnoses, then the H&P, followed by daily notes, labs and X-rays. Yes. The X-rays are physically present on this clipboard and I get the hold them up to the light to read them and feel like a real doctor. 

We write 2 notes per day and then the on call team will write another one overnight. Here is a note from one of my patients this afternoon. Notes follow the same SOAP format that we're taught so at least that part was easy to figure out.

All clinic records are kept in the book below and I'm still not sure how it's organized but somehow it travels with us every Tuesday and Thursday. Below you can also see the red stamp they use to authorize prescriptions and a prescription pad - carbon paper is used to make copies of most documents. 

So, when Epic starts to make your head hurt just remember: at least it's better than this.