Physicians across the country are under a lot of pressure. That’s certainly the case when it comes to figuring out the right balance between documenting patient care and managing their time effectively, says Jeffrey Kagan, a Newington, Conn.-based internist who reviews malpractice cases for lawyers and insurance companies. What also contributes to physicians’ documentation challenges is the need to adequately document the care they’re billing for, says Kagan.
One benefit of using templates with the EHR is they have helped create consistency regarding patient notes — and they also serve to remind physicians about the types of information they need to capture during the visit, says M. Re Knack, a healthcare and litigation attorney with Ogden Murphy Wallace in Seattle.
Before the introduction of templates with the EHR, “a lot of [physicians] had templates – in their brains,” she says. The problem was there was no standardization of those templates across a group of providers.
Still, while templates can make documenting care in the EHR more structured and efficient, challenges arise when physicians use templates that auto-populate much of the information within the patient encounter as documented in the EHR. Some of that information may not be relevant or not currently relevant, says Kagan.
“Let’s say that in the social history you populate that the patient smokes half a pack of cigarettes a day. This actually happened with a pulmonary specialist,” he says. “What had been entered in the EHR many years ago was that the patient smoked half a pack of cigarettes. Three or four years later, that information was never updated.”
Today, that former smoker is a respiratory therapist who hasn’t smoked in years. But her smoking history had been documented incorrectly in the EHR for years because her pulmonologist never updated her patient record. The whole experience was troubling to the patient and embarrassing for her pulmonologist, he says.
To remedy this, physicians need to ask patients at each visit if they’re smokers and make sure to update that in the patient record within the EHR, according to Kagan. Another problem that often occurs with templates is physicians don’t make any changes to the patient record over the course of many visits. From a litigation standpoint, what will happen is any errors that are in the patient’s record will be printed for each visit. That looks really bad, according to Knack.
“There’s something robotic about it,” she says. It’s easy for the patient’s lawyers to make the argument that their doctor didn’t care and wasn’t focused on their patient. What physicians need to do is add some level of “uniqueness” to illustrate the differences between each visit, she advises.
For example, Kagan recommends that physicians add a line in the patient narrative that’s unique to each particular visit. It could be as simple as noting that the patient had a great time at the fair the previous weekend or that they were complaining about the snow or the rain.
