Lying in medical records

[PeripateticMD]

So, this happened to me a while ago. I broke two fingers, went to a doctor at a very well-reputed hospital, got sent out with two "sprained" fingers and without a X-ray order. A few days later, a MD i was in class with stopped me and asked what was going on with my hand. I showed him, he took me to get X-rays, and both were broken and had to be reset. When I asked for my medical records when I graduated, I was bored on the bus and read though them. On the date of that said consultation, he supposedly gave me an X-ray order, examined my hand thoroughly and yada yada yada, which he never did.

I finally brought this up with the chief of orthopaedic surgery I used to work with, and she said this was common. That many doctors now have 'templates' that they just click on and add this to medical records. This way everything often looks the same, they've done everything thoroughly, and most importantly, they cannot be held liable in court! She says she generally sends back records that read like templates and she doesn't use them. But she says it's getting common to use them.

So if this isn't enough of a problem, additionally, most patients do not know that they have full access and rights to have copies of their medical records. I wonder if everyone was to verify what their doctor was saying they did, how much of it would be true...

Just food for thought...

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[epigastric]

I finally brought this up with the chief of orthopaedic surgery I used to work with, and she said this was common. That many doctors now have 'templates' that they just click on and add this to medical records. This way everything often looks the same, they've done everything thoroughly, and most importantly, they cannot be held liable in court! She says she generally sends back records that read like templates and she doesn't use them. But she says it's getting common to use them.

So if this isn't enough of a problem, additionally, most patients do not know that they have full access and rights to have copies of their medical records. I wonder if everyone was to verify what their doctor was saying they did, how much of it would be true...

Having worked for surgeons in a couple of specialties, those electronic templates are the best thing that ever happened to both clinic visits and research. The doctors love 'em because they set up preset statements that work for their job ("I saw Pt X, counseled on Y, Z, and W, discussed the risks of procedure T and the need for follow-up visits A, B and C") that they just click-check onto the record. The hospital administration loves them since they're usually run past the lawyers and everything's documented. And the research staff love them because on a given medical record (assuming you have access) you can easily locate the pertinent details you need.

I've dug through the older paper records, and a lot less gets noted down in them -- with the electronic records, the surgeons can choose their pre-made statements for a matter of record and then manually type in details they don't have templates for ("Pt Z appears to be psychotic and I suggested he seek counseling for his rage issues").

Your story is the first time I've heard of mismatched records like that, which is interesting and a little worrisome, since that's where accountability gets decided. Still going to come down on the side of their being of the good, though.

Now, as for medical record access, I'd argue from experience that it's not knowing that you have access (most people assume, but never need it) but managing to weasel it out of a medical records department...nearly impossible, always requiring taking time off work to physically visit the department with seventeen forms of ID and demand copies.

 

[OncoCaP]

My opinion: EMR's are overall a good thing. They are a tool that can be used properly or abused, and in most of cases I have seen, they are very helpful and beneficial. They don't prevent all mistakes, nor do they stop a physician from putting down something s/he didn't do (actually this is a concern as OP points out) but at least the physician has a template and legible / searchable database of what (should have!) transpired. At least the physician can use a template properly if s/he chooses to. One physician I worked with was able to transmit such electronic records to EMS working with an unconscious patient and this information helped provide important diagnostic clues and led to proper emergency care and saved a life (there are many other benefits as well).

At the end of the day we are dealing with physicians who are human and share characteristics with other fallible humans (some errors, saying things that are not true, etc.). Physicians are not automatically honest anymore than lawyers are automatically dishonest. Just look around at some of the posts from fellow SDNers who will say/do things that are to their advantage even if they aren't necessarily the moral high road. Many of these fellow fallible humans will become physicians who aren't perfect (none of us are).