The following cases illustrate why it is important to edit records created by templates that default to normal and populate the patient encounter report with pre-composed text. When a template uses a limited set of phrases to describe various examination findings, many different patients will have identical text in their medical records. This became an issue in case two below, because the plaintiff’s attorney represented two different patients against the same physician. The attorney capitalized on the physician’s over reliance on pre-composed text in his patient records.
Case One: Failure to Correct Pre-Composed Default Text
Allegation
The EHR automatically generated normal findings for review of systems fields, but the physician did not delete irrelevant systems information and did not personalize findings for the systems that he did review.
Case File
A 30-year-old man was seen by his FP from 2000 to 2012, mostly for allergies, fatigue, anxiety and depression. When he changed physicians in 2012, he was promptly diagnosed with advanced stomach cancer and died shortly thereafter. The patient’s family sued the FP for failure to diagnose the cancer.
Discussion
Because of the “bloated” patient record, it was difficult for experts to determine what had occurred during office visits. Although they thought it was unusual for a patient with advanced stomach cancer to have no symptoms, the patient’s record indicated his abdominal exam was normal at every visit. The FP had a busy practice and he could not recall whether the patient ever complained of abdominal symptoms. His office visit template self-populated exam notes with complete review of systems (ROS) findings that defaulted to “normal” if the FP did not indicate a system was “abnormal.” In other words, even if the FP did not do an exam of a particular system, a paragraph of pre-composed text describing normal findings was entered into the patient’s record, unless the FP checked “abnormal.” For the GI system, the EHR automatically added other descriptors, such as “abdomen soft” and “normal bowel sounds,” etc. The patient record also indicated normal exam results for other systems. Many of those systems exams were not medically indicated for the patient’s main complaints, and the FP was unable to confirm that exams for all systems were completed. Because of the unintentionally fraudulent record entries, the defense team believed a jury would doubt the veracity of the FP’s testimony about the patient’s never making abdominal complaints. The case was settled.
Case Two: Identical Text in Multiple Patient Records
Allegation
Significant portions of various patients’ medical records were identical.
Case File
A physician was sued by three different patients. As litigation in the second case got underway, the defense attorneys, who had worked on the first case, became concerned about the physician’s office visit notes. The exam notes appeared very thorough for each visit, but there was a remarkable similarity among the office charts in the two factually dissimilar, unrelated claims. For example, each office visit note for each patient included the phrase “No skin changes or lesions are noted. Skin and subcutaneous tissues appear to be of normal color, texture and turgor.” For most of his patients, the physician checked “normal” next to “skin exam,” and the template supplied the sentences. The skin exam entries alerted the defense attorneys to a potential problem because skin examination was not indicated in either case. The more they looked for it, the more identical, pre-composed phrases they found in both patients’ records. When asked to explain why the records were so similar, the physician could not. He had never compared the printouts from various patients, and it never occurred to him that checking “normal” in the ROS fields would result in repetitive language in his office notes. The plaintiff’s attorney in the second case accused the physician of not completing examinations as thoroughly as the medical records suggested. However, the expert support was very strong in the second case and it was ultimately dismissed.
The third case involved the same plaintiffs’ attorney as the second case. But unlike the second case, in this case the defense experts could not support the physician’s care of the patient. This time, the plaintiff’s attorney successfully used the documentation issues to the patient’s advantage in settlement negotiations. The defense team knew the documentation could be used at trial to cast doubt about the truthfulness of the physician’s testimony.
Risk Management Recommendations — Templates
While it may be tempting to take advantage of all of the different efficiency tools provided in an EHR system, physicians should instead strive to maximize the accuracy of the documentation. Consider the following strategies when working with templates:1,2,3
Using EHR Efficiency Tools: Recommendations for Physicians
- When a template is used, personalize observations. Do not just rely on the default language provided by the template.
- If it is too difficult to type up why patients presented for treatment, find a way to dictate crucial information.
- Think of what you would like to review yourself in a patient’s record and use that as a guide for relevancy.
- If self-populating templates are unavoidable, go through final record entries and ensure they accurately reflect the patient’s condition and systems you have, in fact, evaluated during the encounter.
- If the template automatically pulls forward information from past visits (e.g., chief complaint, social history), ensure that the information is still accurate.
- Make necessary corrections before making your current entries a part of the patient’s permanent record.
- Know the source of the pre-composed text that is generated by templates.
- Create varied exam templates for different patient complaints and conditions that fit your practice workflow.
- Discuss with administrators any problems with auto-populated fields and pre-composed text.
- Contribute to troubleshooting when appropriate and necessary.
Managing EHR Efficiency Tools: Recommendations for Administrators
- Choose an EHR system that does not use templates that automatically generate content for normal findings.
- Require the user to specifically check off the elements he or she wants to appear in a patient’s record.
- Carefully design templates.
- Use a collaborative approach that involves physicians, clinical staff and representatives from health information management services, clinical documentation improvement and information technology.
- Schedule meetings designed to encourage staff and physicians to determine and share EHR best practices with one another.
- Regularly review the usability of templates and prompts and the printed documentation they create.
References
1. Bowman S. Impact of Electronic Health Record Systems on Information Integrity: Quality and Safety Implications. Perspect Health Inf Manag. 2013 Fall; 10:1c. (accessed 6/30/2017)
2. Dimick C. EHRs Prove a Difficult Witness in Court. Journal of AHIMA. 2010 June 24. (accessed 6/30/2017)
3. Chaudhari, R. Note cloning convenient, but creates dangers for patients and practices. Dermatology World. 2012 June. (accessed 6/30/2017)
