Reacquainting yourself with patients during EHR implementation

Reacquainting yourself with patients during EHR implementation
Reacquainting yourself with patients during EHR implementation
As my office has merged from paper charts to electronic medical records, each patient has to be entered into the computer system. Although some of the established patients' medical history has been preloaded into the system by the staff, each provider must still review and record much of the patient's medical, surgical, family and social history.

Though time consuming, I'm finding that this task is a great reminder of how important it is to briefly review a patient's history during each visit. I'm particularly struck by how often family history is overlooked as part of the medical picture after the initial visit.

We have patients in our practice that had their first visit as teenagers but are now in their childbearing years. It is the rare teenager who knows her complete family history. I'm often surprised when my younger patients know their mother has a history of cancer, but can't recall whether it was cervical, uterine or ovarian cancer. But as women age, they tend to learn more specific history, particularly when they start planning to have children of their own.

I try to briefly review a woman's family medical history at each annual exam, paying particular attention to any significant history of breast, ovarian or uterine cancer. These patients often warrant more thorough screening tests at younger ages, or are even eligible for genetic marker testing such as the BRCA gene.

I'm also interested in any family history of blood clots or venous thromboembolism, particularly when the patient is pregnant or starting oral contraceptives. These women often need further hematological workups to rule out any clotting factor disorders, which are frequently hereditary.

When a patient becomes pregnant, I like to know about her mother's and sisters' pregnancies. Is there a family history of preterm birth, gestational diabetes, preeclampsia, or a difficult or precipitous delivery? Though not entirely predictive, family pregnancy history can offer some clues that help to guide management decisions.

Getting a complete family medical history is an important part of complete patient care. Providers should not only review and update family history at each visit, but also encourage patients to learn more about it whenever  possible. 

Robyn Carlisle, MSN, CNM, WHNP, works as a full-scope midwife at University Doctors and Kennedy University Hospital in Sewell, N.J.

 
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