Nowadays, we as physicians must spend at least as much time and attention “treating our charts” as we do treating our patients.
Even when the charts were strictly paper, it was crucial that we write down everything that was done and seen.
Courts have long taken the premise that if it isn’t in the chart, it wasn’t done. So, if you did an examination or you did a procedure, if it is not located in your progress note, the law states that you did not do it. Stating that you only write down abnormal findings has not been acceptable as an excuse for more than a decade.
It is no surprise that features of electronic recording, open the physician up to legal vulnerability as well.
As is confirmed by Steven Kern, Esq. in his article Hidden Malpractice Dangers in EMRs, “paragraphs of information can be generated with a few keystrokes or even a checkmark…..describing a comprehensive examination in great detail using predesigned templates. Lists of negative findings can appear, neatly printed, with the push of a button.”
Using the wrong template will generate a report that is simply not in keeping with your examination or the patient that you are currently documenting.
It is therefore crucial that you know what is in the chart as well as the template; preferably before the patient even leaves the office.
Patients complain that physicians spend more time with the computer than with them but in this litigious society, just with the paper charts, this is not going to change.
As we have learned in the past, one must take the saying to heart “Cover your Assets”
