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Physicians should always consider how patients will react to seeing their own medical records. In the following case, sensitive information was prominently displayed in each office visit note in the printed out records. This issue became particularly upsetting to the patient when her records were released to her employer’s workers’ compensation carrier.

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.

A subpoena is a request for the production of documents or a request to appear in court. A subpoena may be issued by the clerk of court or by an attorney.

Terminating a physician-patient relationship is appropriate and ethical in a variety of circumstances. However, if the relationship is not ended appropriately, a physician could be liable for patient abandonment or for failure to diagnose or treat a condition. In this special report, NORCAL’s risk management experts present justifiable grounds for terminating a patient relationship and factors that may increase the risk of an abandonment claim.

Records containing information from the wrong patient or inaccurate template-generated or pasted content are just some of the difficulties that can arise when using EHR efficiency tools improperly. As the following cases show, it can be difficult to defend otherwise acceptable care with problematic medical records.