More Contradictions in EMR Charting

Explanation will be necessary

Some electronic medical record (EMR) systems make it difficult for emergency physicians (EPs) to view the nursing notes, says Jonathan D. Lawrence, MD, JD, FACEP, an ED physician at St. Mary Medical Center in Long Beach, CA, and assistant professor of medicine at Harbor/University of California Los Angeles Medical Center, which increases the chance of conflicting information getting into the patient's chart.

"As a physician, you want to be able to easily see what the nurses have written," he says. "When the computer chart gets so voluminous that you have page after page of records, going through them becomes so time-consuming that nobody's going to do it."

This just increases the chances that the nurses' record and the EP's record will have conflicting information, says Lawrence, a situation that makes it more difficult to defend the health care providers.

Lawrence says that in his experience, off-the-shelf EMRs bought from third-party vendors are most problematic, while systems developed in-house in cooperation with actual practitioners work out the best.

"I would say a lot of physicians are not comfortable with EMRs. I don't have too many people that I've run into that are happy with them," he says. "But the type of system used for documentation has to be consistent. If the hospital says we are doing EMRs, and the EP says he doesn't like it, he is not going to be working there."

The EMR may not accurately reflect the encounter with the patient, says Lawrence, such as the patient's attitudes, fears, concerns, or other things that make one patient different from another.

"The other problem with the EMRs is they are often exceedingly inefficient," says Lawrence, adding that some preformed templates don't allow the EP or nurse to proceed unless every box is checked off, which allows for a lot of superfluous material to be inserted in the nursing and physician record.

"That leads to a lot more contradiction between the nurses and doctors that needs to be explained afterward, often much to the plaintiff's delight," says Lawrence.

Filling in Blanks

Since charting with EMRs can be so vague, an EP may be forced to "fill in the blanks" at the time of a deposition, should a lawsuit occur. "But that has its own set of problems associated with it," says Lawrence. "The plaintiff attorney can easily say, 'How can you remember that now, when you didn't write it down then?' 'Sudden memory' looks self-serving."

Any additional time the EP spends documenting is taken away from patient care, he adds. "In general, doctors do the right thing, but mistakes do happen," he says. "What no doctor wants is to do the right thing and then get nailed for it, for an extraneous matter like documentation."

While some emergency medicine groups use scribes to fill out standardized forms for them, Lawrence says that this another source of possible error. He says that one possible solution is to use a standardized form or EMR for simple cases, but allow EPs to dictate complex cases. While standardized forms work well for billing, he says, "that's not of primary importance if you've been named in a lawsuit."

"You never want to defend yourself on the basis of 'I made a clerical mistake.' It just sounds like whining," Lawrence says. "If you made a mistake, own up to it. You would rather have a nice, strong defense — 'This is what I did and why I did it.'"

Paint a Picture

Faced with little except a large number of checkboxes, an EP may simply be unable to remember a specific patient. Every history and physical (H&P) should paint a picture that allows a physician to recall almost all patients, especially the more complicated or unique ones, according to Corey M. Slovis, MD, professor and chairman of the Department of Emergency Medicine at Vanderbilt University Medical Center in Nashville.

"A pure checkbox system paints no picture at all," says Slovis. "Although it's the fastest way to document, it's the quickest way to forget."

Any charting system that has a full and complete H&P could actually improve the EP's clinical practice, according to Slovis, as it's an opportunity to reflect on whether they are doing the right thing, and whether it's defensible.

"Would a lawyer or patient advocate agree with your plan, based on the available information?" asks Slovis. "As long as it all rings true, you are making the appropriate disposition."


For more information, contact:

• Corey M. Slovis, MD, Professor and Chairman, Department of Emergency Medicine, Vanderbilt University Medical Center. Phone: (615) 936-1315. E-mail: