Your EMR charting might be provably false!

Don’t document impossibilities

Entering an overly complete history and examination on a patient presenting with a minor or simple complaint is one danger with electronic medical records (EMRs), especially when time-stamping makes such a lengthy examination unlikely, warns John Davenport, MD, JD, physician risk manager of a California-based health maintenance organization.

In a lawsuit, carelessly documented impossibilities can make a physician defendant appear untrustworthy. “In one recent case, a full preoperative clearance exam was entered and documented more than 20 minutes before the patient was documented to have arrived,” reports Davenport.

Plaintiff attorneys have several goals in examining the patient’s medical record, he explains. “The first is to find documentation that you acted below the standard of care,” he says. “The second is to show that you are careless. The third, and one of the most powerful, is that you are not truthful.”

EMRs “easy to abuse”

While EMRs are more efficient than paper charting, some of the factors that make them easy to use also make them “easy to abuse,” says Davenport. “Such full and automated documentation sometimes leads to discrepancies in the chart.”

For example, an automated phrase documenting a patient’s pelvic exam with notation of a normal cervix is not credible in a patient who has had a full hysterectomy.

Davenport says he has seen an obviously incorrect finding entered into the chart become an issue many times in medical malpractice litigation, such as a male-specific exam performed on a female patient, and inappropriate responses to clearly abnormal laboratory or X-ray findings. “A plaintiff attorney might ask both the plaintiff and the defense expert if the medical standard of care required accurate charting, followed up by a question if the defendant’s charting was accurate,” says Davenport.

Inaccurate charting makes the physician defendant’s charting weaker and the case more likely to be settled, he adds.

“When one or two keystrokes can populate a complete and thorough note, there is the risk of accidentally or carelessly entering false documentation into a patient’s chart,” Davenport says. “Such entries can lead to an attack on the physician’s credibility.”