Prepopulated templates and smart phrases should reflect your interaction with the patient.
Posted in Operational & Staff Risks on Tuesday, November 06, 2018
Smart phrases are Electronic Health Record (EHR) shortcuts, also known as auto text. They are often well-worded, save time and are convenient to use. Although they can be beneficial to use as a starting point, they should be edited by the doctor to be patient specific, visit specific and to reflect the care provided.
During a recent practice visit, an NCMIC risk manager wondered whether the actions referred to in the smart phrases were actually being performed. She noticed that although the notes (based on a smart phrase) stated, “All the previous radiology films were reviewed,” there were no treatment plans or patient-specific notes. This led her to question whether the provider actually reviewed the films.
A smart phrase was even being used to document informed consent. The smart phrase stated, “The risks, options, benefits and alternatives of the procedure were discussed. The patient elected to proceed. Consent was signed prior to the procedure.”
Because the phrase was put into the notes without customizing it to each patient’s situation, the risk manager questioned whether the informed consent conversation took place, and if so, whether the consent met the criteria of “informed” consent. Keep in mind there is a difference between “consent” and “informed consent.” Informed consent generally requires the patient to fully appreciate:
- The nature of the treatment
- All material risks associated with the treatment and the possibility that those risks will occur
- Alternative treatments available and their associated risks
- The risks of not being treated
Similar problems can arise with prepopulated templates. In one case, a patient’s gender differed on the prepopulated notes and the freehand notes. If a plaintiff attorney were to see this, he or she would no doubt question the validity of all the information in the chart.
To put a twist on an old adage, doctors who use smart phrases and prepopulated templates should consider, “If it’s not documented correctly, it did not happen.”