It’s no secret that the bulk of my client base are Doctors. Some are specialists, some are General Practitioners, some are independent, and others from large clinics. Some of them are old-school, and keep paper records; many have opted for completely paperless EMR systems. But what they all have in common is diligent documentation.
It may seem to the casual observer that doctors enjoy forcing their patients to wait. It may seem that they are in no hurry to see the next patient. After all, they’re doctors — at one time all but revered as gods. But behind the curtain, what happens is actually in the patients’ best interest.
Doctors take on a lot of liability by entering the medical profession. They often literally hold patients’ lives in their hands. This is why they have insurance. But of course insurance isn’t enough. Any driver knows that you don’t crash into cars with abandon, knowing that your insurance will foot the bill. The aim is to avoid any insurance issues altogether.
The medical profession, much like the IT industry relies on information, and that it be up to date. So after any appointment with a patient, doctors spend time making notes. Sometimes these are just rough notes to jog their memory later, other times they will speak into a transcription machine to record their notes for later, and in some cases, the doctors will opt for a speech recognition program to directly transcribe the notes from their voice to the computer screen.
However they do it, the result is the same: information recorded for reference. And there you have it. Documentation. It’s not sexy, but it’s vital to care, both for people and for technology.
Doctors do it because lives are at stake. Being that I service the systems that the doctors rely on for patient care, I do the same thing for much the same reasons. I can’t be expected to remember an issue that occurred 18 months ago in any great detail, but provided I made adequate notes of my work at that time, I can refer to them later and immediately grasp what the issue was without wasting time investigating all over again. IT documentation at it’s finest.
After every day, I spend a couple of hours documenting all the issues I encountered in that day. Wireless network configurations, passwords, IP addresses, anything that my clients or I may need for reference later gets documented. I take the information from my little notebook and transcribe it to my records management system. If the client’s infrastructure is large or complex enough to warrant it, I’ll sometimes write a booklet listing all the components and configurations of their IT systems — a booklet that I actively keep up to date and resubmit to the client for their records once or twice a year.
I don’t even want to get into the nightmares I’ve experienced by starting with a new client who has no IT documentation. It’s a long and drawn out process collecting all the information from scratch. Vendor contact information, account numbers, warranty expirations, configurations — the list of information captured is extensive. It’s common for even a small client to have a 20-page IT documentation record, when completed.
All of this adds accountability and a quality to our work at McLean IT. From this information we can derive when a service was performed, why it was needed, and who performed it. Information that is invaluable when you discover you need it.
I an a specialist who plans to see 6 to 8 patients in an office I rent one day a week. I would like to use DD for consult letters, and have some means of electronic storage of records. Presently I have DD med 8 and desk top computer at my home. I envision obtaining a laptop to access hospital reports and images while I am seeing patients at the office and to dictate letters. Can you advise me about the choice of laptop and electronic storage of my letters?