How the EHR can ruin your documentation—and increase legal liability

EHR SOFTWARE CAN make it possible to get notes into a patient’s medical record without waiting for a transcriptionist. But these programs often use shortcuts that can make hospitalists look lazy or ignorant—or get them into serious legal trouble like a malpractice lawsuit.

Consider the following three notes, which provide real-life examples of issues created by the EHR:

• “Patient admitted yesterday with complaints as follows:” (a note written a week after the patient had emergency surgery).

• “Foley catheter present” noted three days after it was removed.

• “Denies respiratory complaints” (patient just out of ICU one day after extubation).

I’ve worked with malpractice attorneys for 15 years now as an expert witness. Sloppy documentation not only makes it hard to defend yourself; it makes it hard for me to defend you.

When the EHR tries to do your job

“Auto-populate” happens when the EHR anticipates what you want to say next. If your physical exam yesterday included examination of the abdomen or presence of a PortaCath, some systems will try to insert some language about those today, and you may be just a click away from putting outdated or wrong information into the chart.

Sloppy documentation not only makes it hard to defend yourself; it makes it hard for me
to defend you.

The EHR’s review of systems, for example, offers multiple options for symptoms, some of which you may not have asked about. “Appetite normal” may sound good until the nurse points out that the patient is eating only 10% of the meals provided, and then you have to go back to the computer for an addendum. And of course, re-reading your notes before signing them can save you from some mega-mistakes.

Physical exam is vulnerable to auto-populate as well, by offering options you may not have thought of. Did you examine the abdomen closely enough to be sure there was no rebound tenderness? Or did you just click on “no tenderness or organomegaly” to make the note look more complete?

Importing lab and imaging reports shortens your writing assignment, but not all abnormal or rapidly changing values are going to be highlighted in red. Read all the way to the bottom of the radiologist’s report too, so as not to miss these important words: “Cannot rule out _____.”

Check for “normal” results that have changed markedly. A platelet count of 175 may not get flagged—but if it was 300 yesterday you may want to look at that imported med list and hold the heparin until you’re sure it isn’t causing new problems.

Documenting the clinical course

Every day a patient spends in an acute care hospital is supposed to be different. For example, surgery on day No. 1, tolerating liquids (or not) on day No. 2, and changes in condition up to the day of discharge.

You learned in med school to ask questions like, “How do you think you’re doing?” and “What’s new?” Your daily progress note should reflect that you asked those questions and got answers. This will help not only the person writing the discharge summary, but a partner or resident who is new to the case.

Free-texting a couple of sentences takes only a minute or two longer than clicking on options offered by the EHR or copying what you (or the GI consultant) wrote yesterday. Changing the wording, too, makes it clear that your brain was actually involved.

You were taught better than this

I hope your instructors in medical school made you describe patients’ problems with more than canned phrases. One of our most demanding professors once had me describe a complete physical exam without using the word “normal” or to at least replace that single word with phrases like, “Bowel sounds normal in frequency, pitch and character in all four quadrants.”

If you’re complaining that you don’t have time to document patient complaints and physical examination, stop and ask yourself these two questions: Just how much time will the additional documentation take? And what are you going to do with the time you saved?

Is your patient load so heavy (the Society of Hospital Medicine recommends an average load of about 20 visits per day) that a couple of extra minutes per patient will disrupt the group’s schedule? If so, you need to have some serious discussions about workload.

The bottom line

An EHR is only as good as its programming, and its canned phrases may add length to a note but not accuracy. Not only do your partners and consultants need to be able to trust your notes, but your patients and colleagues need to know that the information you share there is reliable.

Good documentation gives a clearer picture of what is happening, both now and later. Make sure that shortcuts do not cut out something important or add something that really isn’t there.

Stella Fitzgibbons, MD, has taken care of hospitalized patients since the 1990s and has testified in dozens of malpractice cases.