Hektoen International

A Journal of Medical Humanities

Tag: problem-oriented medical record

  • Decoding doctor-speak in the era of OpenNotes

    Jennifer WinekePhiladelphia, Pennsylvania, United States Modern-day doctors share a common dilemma: how do you get all of the necessary information into the electronic medical record while still being present with the patient? Every doctor I have talked to approaches this challenge a little differently. Some acknowledge the impersonality upfront and apologize to the patient (“I…