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If you go along with my definition of medical records, computerized clinical narratives would constitute the major part of electronic medical records (EMR). EMR offers many benefits as better accessibility and increased legibility. However, concerning patterns emerged when full computerization of medical documents was carried out. I will present Weir and Nebeker (2007) qualitative study done to assess Veterans Affairs EMR computerized clinicians’ narratives. The studied system offered clinicians with multiple methods to enter data:

1. dictation (only 1% of documents were dictated)
2. manual entry facilitated by:
• templates
• objects. objects are parts of documentation that could be used multiple times as patient identification, medication lists and problem lists.
• copy and paste

Negative effect on work process was one of the emerging themes. This is usually noticed with any sort of computerization. However, much more concerning themes, that can undermine the purpose of clinician documentation appeared. These themes are:

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At last I got my hands on the landmark article by Nygren and Henriksson (1992). According to Google Scholar this article was sited only 101 times. I believe that the research presented in this article is underappreciated. This qualitative study offers the best insight into how paper medical records are actually used by physicians. This article studied what physicians do in out-patient setting. I find this rare in the study of Medical records in general. Most studies focus on in-patient services. The use of paper medical record (P-MR) by Swedish physicians  was studied. Yet, the findings are generalizable to the places I practiced; Canada and Saudi Arabia.   Seven physicians with at least 5 years of experience were interviewed. These physicians represented the following specialties: general practice (2), cardiology (1), gynecology(1), surgery (1), plastic surgery(1), clinical physiology (1), and psychiatry(1).

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