Commentary — July 2017
Tex Med. 2017;113(7):11-12.
By Camille Ayoub, DO
I met B in the emergency department (ED) during my first month on pediatric wards. She had been diagnosed with hand, foot, and mouth disease (HFMD) in the ED two days earlier. I learned she never had any rash or oral lesions, but had been in contact with another child diagnosed with HFMD one month earlier. The mother's main concern was B's fussiness, fever, and desire to just "lay with mom." My senior resident, concerned about discrepancies in B's story and diagnosis, insisted on a complete, head-to-toe exam. Like most 2-year-olds, B was tearful just at the sight of doctors, but when my senior tried to move her left leg or apply pressure to her left hip joint, she swatted his hand away. We attempted to stand her up, but she refused to bear weight on her left leg. After some discussion and one MRI later, it was discovered B had a septic hip.
In the electronic medical record (EMR), it was documented that B had a normal musculoskeletal exam at both of her ED visits that week. Furthermore, there was no mention of B having a rash or oral lesions consistent with the diagnosis of HFMD. Did she really have a normal exam at those times or had a default template with normal findings been used and the provider forgot to customize it? Alternatively, had the provider not done a complete exam, but left the prepopulated template in place anyway?
The evolution of the EMR has been both great and challenging. It allows us to access patient records remotely, review vitals and test results as soon as they are completed, and easily share patient information among medical personnel. If used properly, it can also help with patient safety and transitions of care. But with the thoroughness the EMRs can provide, they can also be tedious and time-consuming. The number of clicks and windows involved to enter orders, write notes, and reconcile medications — all essential to patient care and safety — creates "click fatigue," and important details can be overlooked.
The degree of documentation required and the demands of a high patient load have forced providers to create time-saving history and exam templates for EMR documentation. When used incorrectly, these shortcuts can be detrimental. Typically, templates are a provider-created, generic note, often prepopulated with normal findings that are meant to be customized for each patient. As in B's case, this predisposes to scenarios with discrepancies between patient exam and diagnosis. There are important lessons here on being honest and meticulous.
First, only document what you have actually done. While templates improve efficiency in documentation, they can also be our downfall. With the demands of high patient load, it's easy to use a prepopulated template intending to customize it later and then forgetting to do so. It is also easy to leave a precompleted template's default findings if you "mostly" did a complete exam.
Second, we still must do our own full history and physical, or we risk missing something. The luxury of having other providers' notes before seeing a patient gives us a bit of an edge. We get the CliffsNotes version of the history and physical, and if we are lucky, a pretty good idea of what the provider thinks is going on. However, you should not rely on another provider's exam, especially because exams are dynamic and may change with time. As I was reminded with B, it is dangerous to assume findings because, as obvious as this sounds, you never know until you check.
Unfortunately for B, she went to the operating room twice during the eight-plus days she remained in the hospital, and she required intravenous antibiotics. By the time of her diagnosis, she also had MRSA+ bacteremia.
Could we have shortened her hospital course had she been properly diagnosed at her first ED visit? I would like to think so. For at least three days, she was only getting sicker.
So, despite the benefits of EMRs, they are definitely a double-edged sword. "Click fatigue" and improper documentation pose a risk to patient safety. Medical professionals can work to improve our use of EMRs one chart at a time. A good first step could be increased diligence in modifying precompleted templates for each patient. The use of the EMR is just one part of the many things we must balance in order to improve patient care.
Camille Ayoub, DO, is a first-year family medicine resident at The University of Texas at Austin Dell Medical School. Swati Avashia, MD, assistant professor of medicine in the family medicine residency program at Dell Medical School, contributed to this article.