Use Medical Record Templates With Care

Some medical offices opt to use templates in creating medical records. While templates can be wonderful timesavers, do not use them without precaution. Here's why:

The default setting on some templates is a positive finding. If you use this form of template, especially electronic, failure to indicate that the patient does not have that particular finding will result in a chart indicating a positive finding anyway. The same type of problem arises with templates that default to a normal finding. You must review each entry on each template to be sure you chart accurately in every field.

  • It may be difficult to find a template applicable to your practice specialty. Using a template is not efficient if you have to confirm every field on every patient, even though half the fields are inapplicable. This is especially true for pediatricians and physicians who specialize in one organ.
  • Templates tend to make every entry on every patient sound the same. The personal care and individual treatment you provide your patients may not be apparent if your patient's medical records wind up in a jury box or before the Texas Medical Board. Never use templates exclusively; be sure there is opportunity to enter narrative thoughts, observations, and occurrences to individualize each record.

Every medical record is an important legal, financial, and patient care tool. Need answers about how to use it most effectively?

Managing Your Medical Records is a TMA publication based on our members' most frequently asked questions regarding medical records, including consent, storage and destruction of records, releasing records, and disclosure. This program is accredited for 4 hours of AMA PRA 1 CME credit, including 4 hours of ethics/professional responsibility. Physicians insured with the Texas Medical Liability Trust may earn up to a 3-percent discount (not to exceed $1,000) on their professional liability premium by taking this course.

 

Content reviewed: 6/12/2008

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