The ethical problems of template charting

It’s clear to many of us in clinical practice that the medical record has been hijacked by the coders and bean counters. What’s equally clear, at least to those of us who have been in practice for a long time, is that the coders and bean counters were aided and abetted in this effort by the rising popularity of template based medical records. Templates became popular in the paper era and are rising to a whole new level with electronic medical records.

Potential benefits of templates are more efficient coding and documentation. Paragraphs of clinical information can be generated by a few clicks of the mouse. What’s more, the template prompts the user to document more components of the history and physical exam to enhance coding.

I’ve often wondered whether these templates push the envelope of fraud. Through the years I’ve seen template generated notes with what I thought was gratuitous documentation. (It may not be fraud, but do you really need a 12 system review and a comprehensive physical exam for a single problem encounter?).

I’ve never directly observed or verified a case of template generated fraud. But this blogger has, and it’s rampant in his emergency department:

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…

For years a logical fallacy has been shoved down the throats of doctors, and it goes like this: “if you didn’t document it you didn’t do it.” Is it any surprise, then, that some doctors might embrace the inverse of that statement, the equally false premise that “if you did document it you did do it?" Those electronic templates make it all too tempting and all too easy.

I agree with blogger ER Murse that the electronic template is merely the enabler. Part of the recipe for fraud is a susceptible provider---one who is under financial or administrative pressure to “improve coding and documentation” or, perhaps, one who buys into the logical fallacy cited above.

The ER Murse post has links to some good documentation and compliance resources for EMRs, but for the most part template facilitated fraud has been missing from the discussion of unintended consequences. Maybe it’s an elephant in the room that people would rather not talk about. It needs to be on our radar screen.