For those of us who review electronic medical records day after day, there is always a concern of whether they are accurate. In the “old days” when a doctor wrote down his observations and actions upon examining a patient, we assumed the information in the record was probably complete and correct. After all, why would the doctor or nurse take the time to write it down if it didn’t happen? An old saying is that “if it’s not documented, it wasn’t done.”
Now, when you see a lengthy list of all the items covered in “review of systems,” and the patient tells you the exam only took less than a minute, there seems to be a discrepancy. With the advent of electronic medical records, that assumption of accuracy no longer holds. With pull-down menus and pre-programmed paragraphs, the electronic system allows a doctor to simply click a button to record what happened, and therefore what would be billed.
A recent study published in the JAMA Network in September of 2019 found that nearly half of the physical exam findings documented in the electronic record never happened. A team of observers noted what was actually done in numerous exams and then compared that with the electronic record.
The financial incentives for a hospital to bill for more complete assessments and exams may be a partial explanation. The fact is that the electronic record is a billing document, and often not a true reflection of what the physician has done. There are also time pressures on providers to record, for example, a full neurological exam when there was only a quick assessment.
The dangers in this practice are obvious. For example, the electronic record notes that a doctor did a complete review of systems and that the patient was neurologically intact. When there are focal neurological signs the next day, the provider assumes this is a new development and may take different actions than if it was known the symptoms were there 24 hours earlier.
While the old saying was “if it’s not documented, it wasn’t done”, perhaps a new one is more accurate: “if it is documented, it probably wasn’t done”.
