Page 17 - Part Two Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

Similarly, the use of templates, or click boxes, can create an

inaccurate clinical picture, potentially failing to adequately

describe the complexity of the patient’s condition because of the
limitations that are created within the template itself. Because a

template can prompt review of certain systems or guide the

assessment to seek specific findings, some providers may be led to

look for only those findings or diagnoses. As a result, a template

can create tunnel vision that makes it easy for the provider to

overlook other significant clinical findings resulting in a delay in
diagnosis or treatment of the actual problem.

Consider the following case:

CASE STUDY

A 58-year-old patient with chronic hypertension came to the
office during the busy flu season with complaints of nausea and

the staff selected the “nausea/vomiting” template. When the
physician arrived in the exam room, he assessed her GI systems,

but because the vital signs were not visible in the portion of the

medical record that was viewed by the physician, the physician
didn’t see the BP of 205/110 recorded by the staff and not

mentioned to the physician. His assessment was lacking any
differential diagnoses or documentation of a medication

reconciliation where it would be discovered that the patient had

not taken her regular medications (including anti-hypertensives)
for three days due to nausea. The physician prescribed

medications for nausea and sent the patient home. Unfortunately,
later that day the patient died from an intracranial bleed.

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