The other day at work I was taking care of a patient that was in an MVC. She was in spinal precautions and complained of neck, and leg pain. Our ED Physician came in and did his exam from the door way holding his Tablet PC marking off items into the Electronic T-sheet while he asked a few basic questions. He was in and out in less than a minute. Out of curiosity, I reviewed his documentation and not surprisingly there was a comprehensive assessment documented. Abdominal findings, lungs sounds, heart sounds, pupils and ocular movements, neuro exam, all beautifully documented in a long paragraph and all normal. Not bad for an exam conducted from the doorway. I watched without comment throughout the day and noticed the same general exam pattern on most of his patients and the same comprehensive documentation of his exams. About one half of the Docs in this ED practice operate in a similar way although he is the worst. Others actually perform the exams they document and coincidental, have the longest door to provider times. They are being pressured to speed up their times. Exams do take time. This same Physician above is the promoter of Triage Bypass policy being promoted at the ED I work. He claims that asking patients the same questions and doing the same exam he will do (or not do) in Triage is an unnecessary delay and negatively effects patient satisfaction scores. So now when beds are open were rushing patients back with nothing more than an eyeball assessment to make them happy and get them to the Doctor who does a 1 minute exam from the doorway and fudges the chart. Guess what, our patient satisfaction numbers are way up and our length of stay is down. Administration is happy.
Fudging charting is not isolated to Physicians and Electronic Documentation. Another ED I occasionally work at I see nurses regularly check off on the paper T-Sheet items that were not done. I even see some make up phony discharge vital signs rather than take the time to do them. I recently had a discussion with my Charge Nurse who audits charts prior to the end of the shift. She was all over me because I was not checking off the boxes which said ID Band confirmed, Bed in low position, Side rails up x 2, patient gowned, blanket provided, and including discharge vitals. I told her, the patient was a Fast Track patient and discharged within minutes of arrival, I didn’t do all those things. Doesn’t matter she said, “Just check the boxes or we get dinged”. I told her to go ahead and ding me, make my day. I’d rather get dinged for not checking boxes than falsifying a chart. My stand is being viewed as I'm just being difficult.
The question that this begs is whether the problem is with the individuals or the tool. My opinion is a poorly designed tool facilitates shortcuts in certain individuals who are either lazy, dishonest, or very uninformed about what they are charting. Templated charting, either paper or electronic, can cross the line rapidly into fraudulent charting in those individuals. I don’t think they view it as fraud and are able to rationalize their actions because they feel they are only documenting to satisfy a regulatory requirement. In the case of documenting items not done to obtain a higher billing level there is no question in my mind that fraud is occurring.
A good article, here, at AIS Health.com list some of the issues with templated electronic documentation.
"Physicians love electronic medical record (EMR) templates because they make documentation faster and easier, but abuses, such as cloning and "exploding" notes, are jeopardizing reimbursement and compliance, experts say. If too much information is replicated from one EMR to the next, there is little to distinguish patient encounters, and that undermines physician attempts to establish medical necessity — the foundation of Medicare reimbursement — and perhaps implicates quality of care."
My first example I listed is an example of an exploding note. Basically, an electronic template is pulled up for a specific complaint, a few mouse clicks is all it takes to default all values to normal and a beautiful paragraph is produced based on programming code behind the scenes listing all the elements of a comprehensive normal exam. To change the defaults you need to click a few more times either selecting common abnormal values or free text the abnormal finding in. The path of least resistance is the former.
"Cloning can work for elements of the history, but cannot and should not be used for the history of present illness, the exam or the medical decision-making portion," the compliance officer says."
Cloning refers to pulling data forward from previous visits or from another persons note, usually via copy and paste, into your note and signing it as yours. Very helpful for a long history which does not change but problematic for a physical exam that you did not do. In Academic Medical Centers its common for the Student to do the exam, the Resident pulls forward the note as theirs and on rounds the Attending does the same and signs it electronically.
Templated charting both paper and electronic has caught the attention of many in the HIM community. The American Health Information Management Association has a good paper on Guidelines for EHR Documentation to prevent Fraud. The article list many types of documentation problems and recommendations and the appendix gives real case examples.
“Electronic documentation tools offer exciting new time-saving and validity checking features designed to enhance communication for all health record users. They address traditional, well-known requirements for documentation principles, while supporting expansive new HIM capabilities. However, use of these features without appropriate management and guidelines may cause invalid auto population of data fields, manufactured documentation to enhance expected reimbursement, and other undesirable outcomes”
What is the solution? It’s certainly not to stop using templated charting or electronic charting. It won’t be long before everyone is doing it. A strong set of standards for EMR design and training is essential. Charting tools that require structured data for most exam documentation would help. Rules against copying notes of others and calling them yours and the clear understanding that if you have charted something you did not do you have committed fraud. You can report fraud here. Templated charting, if used correctly, prompts the individual to perform complete exams and documentation and can enhance patient safety.