Illegible handwriting on the part of physicians and nurses in hospital and outpatient charts is often said to be the reason for the electronic medical record (EMR). The virtues of the EMR are extolled far and wide and various gimmicks are incorporated to facilitate charting. For example, templates can be utilized that go into great detail describing a normal examination. If the examination is not normal when the doctor sees the patient and uses the EMR “canned” note, then the doctor must change the template and enter positive the findings in the patient's history and physical examination. However, if the “standard” entry is not factual for the patient being seen at a particular time and goes uncorrected, then we may be left with absurdities and contradictions. For example, in a recent chart review, I read about a blind man with 20/20 vision. Even though the chief complaint for the office visit after craniotomy for a pituitary tumor was “blindness after surgery,” the note itself went on to document 20/20 vision in both the right and left eyes and a normal neuro eye examination for both eyes. In another chart review case, a patient who was treated in a halo orthosis for a cervical fracture was said to have a “supple” neck with “normal neck range of motion” while still in the halo during an outpatient encounter with his neurosurgeon. I have no doubt that neither of the physicians who made those entries were lying (making intentionally deceptive statements).[ 1 ] They told a story that could have been true but was not. I think we call that fiction or perhaps B.S. or balderdash as suggested by Frankfort.[ 2 ]

References

1. Bok S.editors. Lying: Moral Choice in Public and Private Life. USA: Pantheon Books; 1978. p. 16-

2. Frankfurt HG.editors. On Bullshit. USA: Princeton University Press; 2005. p. 5-