Two examples were presented at a recent conference. One was a cut and paste propagation of a minor problem. The other was an EMR problem related to templates.
- In the history, some doctor at some point wrote “patient deeniied abdominal pain…” That misspelling was likely related to heavy fingers on select vowels. This misspelled phrase found itself transmitted on multiple entries. Clearly cut and paste. And likely the patient was never asked about abdominal pain by any subsequent doctor. The record suggests the physician knew how to spell “denied” because it was spelled correctly elsewhere. What this cut and paste does reveal is that the doctor ignored the question. Similar to the physical finding “WNL.” Some believe that stands for “Within Normal Limits.” Others believe it stands for “We Never Looked.”
- An ob-gyn practice uses an EMR system with templates specific for ob-gyn patients. That would presumably mean it would be limited to female patients. Well, one ob-gyn took care of a female patient. Her husband was in the room and had some dermatologic condition – I can’t recall exactly – but it probably was a skin tag. Something minor. The husband asked if it could be removed. Sure. And like a good doctor, the ob-gyn entered documentation of the procedure into the EMR. The doctor entered free form text and took no further action. But the EMR assumed that all else was WNL. So, it included “No recent vaginal discharge” in the Review of Systems. Well, it would be unusual for a male to have vaginal discharge. So, “No recent vaginal discharge” is technically accurate but mostly because there is “No recent vagina.” Not sure the best way to counter this other to enter that this patient was a male and any no affirmative Review of Systems was performed. Then you’d look smart even when the EMR is dumb.
What do you think?