Wednesday, July 6, 2011

Computer generated templates

Want to have a long impressive note that may or may not have anything to do with the reason for an office visit?

Use some of the various computer templates on the market.

It now not unusual to receive a 5 page note from a specialist from a follow-up visit.

I've seen 10-12 page primary care notes, for one visit.

Don't get me wrong. The computerized patient record has clear advantages.

The fact that it is interpretable is an advantage.

The fact that it's readable is also a disadvantage.

Many times wrong information is copied and pasted from note to note.

Patients often bring outside records in which they have made corrections to such items as their social history.

Its' also generated some lively discussions when a complete physical is recorded and the patient is sure the surgeon only did a brief exam of their umbilical hernia.

Medical legally: if it wasn't recorded it wasn't done.

The opposite is also true: if it was recorded and wasn't done, it's FRAUD.

I'm certain that malpractice attorneys love the computerized patient record.

Given technology now available, it's not a stretch to envision patients secretly taping an encounter and then having their attorney compare it to the computerized patient record.

My recommendation: don't record things that weren't done. If using templates, delete parts that were not done and are not needed.

Don't have your integrity questioned due to ignorance on how to adapt a template to the actual visit that took place.

Also, if a visit can be well documented in just a couple of lines ( for a brief follow-up visit after an I and D of a cyst, for example), free text the note (type it!)-don't use a template.

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