{"id":"7241ff7b-e37c-4c57-ab1c-b9a8d676b0da","slug":"from-writing-illegibly-to-composing-fiction-the-story-of-a-blind-man-with-2020-vision","title":"“From writing illegibly to composing fiction: The story of a blind man with 20/20 vision”","authors":["Howard Morgan"],"abstract":"Background: Illegible handwriting by healthcare providers has been a significant issue leading to the adoption of electronic medical records (EMR). While EMRs are designed to enhance documentation, they can also lead to inaccuracies if standard templates are not appropriately modified to reflect the patient's actual condition. Methods: The article presents a review of clinical charts to illustrate the discrepancies that can arise from the use of EMR templates. Specific cases are highlighted, including a patient documented as blind yet noted to have 20/20 vision, and another patient with a cervical fracture described as having normal neck motion while still in a halo orthosis. Results: The review revealed instances where the EMR entries did not accurately represent the patients' conditions, leading to potential confusion and misinterpretation of clinical data. These examples underscore the importance of accurate documentation in medical records. Conclusion: The findings suggest that while EMRs aim to improve documentation, they can inadvertently perpetuate inaccuracies if not carefully managed. It is crucial for healthcare providers to ensure that the information recorded is factual and reflective of the patient's true clinical state. Keywords: electronic medical records, documentation, clinical accuracy, chart review, neurosurgery, patient care","thumbnailUrl":null,"publishDate":"2014-08-05T00:00:00.000Z","doi":"10.4103/2152-7806.138204","categories":["Original Article"],"fullTextUrl":"https://surgicalneurologyint.com/api/articles/7241ff7b-e37c-4c57-ab1c-b9a8d676b0da/pdf"}