Sometimes I feel a little like a dinosaur. I like paper medical records. I like them printed out, organized and ready for my review as a legal nurse consultant.
Medical record review: which is faster?
Although I received PDFs of medical records, I used them to print out paper records. Using preprinted medical record tabs, I put the records into categories, starting with the oldest record and ending with the newest record of that type.
I know that medical records can be rearranged using Adobe Acrobat once they are scanned and saved as PDFs. Intellectually I understand that. I own Adobe Acrobat. However, I see the process as cumbersome for large records. Is it faster to grab several sheets of paper and rearrange them in the correct order, or to set up a file called “Nursing Notes” on the computer, and drop and drag each page? I like paper medical records for ease of organization.
Is it faster to slip a preprinted index tab on top of a stack of medical records, or to mark each record according to its type and then drag it to the right spot?
Scanned medical records and expert witnesses who like paper medical records
How would an expert witness feel if he or she got scanned records instead of paper records? I routinely received thanks from our experts at Med League because we organized the records for them.
Would an expert be comfortable going into a deposition with a laptop and scanned records and be able to answer, “Where did you find that in the record?” There is enough tension in a deposition room as it is without the expert hunting on the screen for the answer to that question.
Furthermore, I’ve asked my attorney clients if they have seen an expert come to a deposition with a laptop and scanned records. So far, no one has. This doesn’t mean it is not occurring.
One of my clients recently asked me why I like paper medical records over records that have been scanned. The attorney’s perception was that he would save money if he supplied a disk with medical records. He did save money – on the shipping costs. But I wonder if handling PDFs is a time and money saver.
What do you think? Do you prefer paper or PDF medical records?
Pat Iyer MSN RN LNCC is president of The Pat Iyer Group. Learn more about handling medical records by participating in an all new webinar, Medical Record Traps and How to Overcome Them. Get details at this link.
Janice Freel says
06/20/2014 at 3:52 PMI prefer paper records mainly because I’m accustomed to them. I believe it’s easier and quicker to organize than it is to navigate through EMR and create new files.
pat says
06/20/2014 at 8:45 PMI’m with you, Janice.
Caryn Jaffe says
08/05/2014 at 4:41 PMI agree that paper charts are much easier to use. I recently worked on a case in which records has been printed out from an electronic medical record.. and I found the same note in different format a number of times. The vital signs flowsheet was not a flowsheet and difficult to understand and organize. Had I not been able to play around with the order of the papers and reorganize the notes, it would have taken quite a few extra hours of work to figure out the true issues of the case. Perhaps I am old school, but paper and pen with a good highlighter is how I like to work. Computer savvy I am, but old school too.
pat says
08/07/2014 at 4:51 AMGreat points, Caryn. You have an advantage over an attorney in being able to understand the data even if it is scattered.