North Carolina Policyholders: Notice to policyholders recently affected by severe weather. 

Use Care with Pre Populated Templates and Smart Phrases

Smart phrases are shortcuts, also known as auto text, dot phrases, etc., in Electronic Health Records (EHRs). The phrases are well worded and can save time. A smart phrase can be used as a framework for the note; however, the phrase needs to be edited by the physician to demonstrate it was patient-specific and visit-specific, and the actions indicated were taken. As always, the physician is responsible for the accuracy of the healthcare record.

During a recent assessment, I wondered whether the actions referred to in the “smart phrases” were actually completed. When a smart phrase stated that “all the previous radiology films were reviewed” but there were no patient-specific notes or treatment plan, it wasn’t clear whether the provider actually reviewed the films. In other words, I was unsure whether they performed the action noted in the smart phrase.

One smart phrase was even being used to document informed consent, stating “the risks, options, benefits and alternatives of the procedure were discussed including but not limited to bleeding, infection and potential death. The patient elects to proceed. Consent was signed prior to the procedure.” In addition to whether the consent conversation was done, this statement also raises the question about whether the consent was actually “informed.” Remember, there is a difference between “consent” and “informed consent.”

Similar problems can arise with prepopulated templates. In one case, the gender of the patient varied in the prepopulated notes and between what was entered freehand. If a plaintiff attorney were to see this, they would no doubt question the validity of all the information in the chart.

Using prepopulated medication lists may save time, especially when most of the population is taking five or more prescription medications. However, since medication management is a leading cause of claims for most specialities, it is good practice to confirm the patient is taking the medication as prescribed. This way you can address any noncompliance or nonadherence issues. A simple note after the review of the medication with the patient may help illustrate and validate the discussion and review. Remember the old adage, “If it is not documented, it did not happen.”

As a policyholder, if you have questions about these risks, please contact us.

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