I know my medical records are not perfect but occasionally I get a chuckle when reading records, from other physicians, on a patient of mine.
Here's one from today:
Under the Past Medical History (PMH) section:
Surgical: No previous surgery
Under the Physical Exam section:
There are scars consistent with the previous surgeries listed in the PMH.
What made it really amusing was that I looked over notes from monthly visits for 6 months.
All notes had the same verbiage.
I know why it happens...computer generated templates!
Its actually probably easier these days to be a medical malpractice attorney than it used to be.
Everything is computer generated, printed and easier to read.
Obviously, mistakes are still possible.
It's the element of fraud (to increase billing codes), however, that needs to be held in check.
It's OK to use templates but sections that were not done need to be _______ (deleted).