By Brian L. Grant, MD

The timely New York Times article, “A Shortcut to Wasted Time,” describes problems arising from improper use of record keeping.

It is important that those involved in medical care and treatment review, including those requesting these services understand the capacity of electronic systems to be misused.

There is nothing wrong with such systems and they are not going away. But as with most information tools, the quality of what is generated is only as good as the input, in this case the clinician doing the work.

Electronic systems can be abused and misused in many ways. And one does not need an expensive record system to misbehave. Microsoft Word will do. In the course of reviewing records, I have seen a number of abuses.

Here are a couple of ways to identify the misuse of medical record systems:

• Boilerplate used where unique data is required: A psychotherapist working with a patient over time reports the exact same mental status findings from week to week, in the same words. People change and emotions are not static. The clinician demonstrated laziness and questionable competence when each note read substantially the same, courtesy of cut and paste or template.
• Normal findings reading exactly the same: Physical and mental status findings have many variations. This includes normal findings. When an orthopedist reports the same range of motion on multiple patients, where the normal range can and does vary, a reader can conclude that the measurements are likely inaccurate, and the overall credibility of the examination is in doubt, including whether the measurement was actually taken.

In the old days of handwritten or dictated notes, each entry was unique and required that the clinician take specific action to report a given finding. Now with a click of a mouse, one is capable of filling a page or more with content. Just because one can, does not mean one should.

If you create records, demonstrate thoughtfulness and do not use boilerplate for findings. A template can be useful as a guide to what content should be included for a particular assessment or complaint. And typed records are legible unlike most handwritten notes.

If you read records and see findings reported in such a way to suggest that they were computer and not clinician generated, it should raise red or yellow flags about the overall quality and credibility of the treatment records and the clinician describing the treatment.

The abuse of record systems is a significant unintended but entirely predictable consequence of the technology. I invite readers to comment on their own findings and observations from working with or reviewing the work product of such systems.

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