Over the years I’ve known many psychotherapists and psychiatrists who have refused to see patients because the patients’ medical record was not available before the session. I have to admit that as a clinician I never seemed to get as much from the chart as a lot of others claimed they did. I always thought they were being prima donnas to some extent.
Of course, unless you have eidetic memory, it makes sense and seems only like good practice to look over a chart before seeing a patient. It helps refresh your memory about the patient, treatment objectives, and of course other important issues such as allergies and dangerousness. Of course there is Stawar’s Law that states, “The more you prepare for a session, the less likely the patient is going to show up that day.” This is a nearly perfect negative correlation.
With the advent of the Electronic Medical Record (EMR), it is now possible to see how much clinicians actually access their patients’ charts before sessions. While you still can’t tell what is read, you can determine what parts of the chart are accessed. At first glance it doesn’t appear that clinicians are looking at very much in most cases.
I wonder if this might become an issue in lawsuits. Will patients’ attorneys be able to subpoena logs, showing if clinicians actually opened the patient’s chart before they saw them for a session? Will there be torts over failure to show due diligence in meeting this standard of care? Perhaps this will be another unintended consequence of the EMR.