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The following cases illustrate why it is important to edit records created by templates that default to normal and populate the patient encounter report with pre-composed text. When a template uses a limited set of phrases to describe various examination findings, many different patients will have identical text in their medical records. This became an issue in case two below, because the plaintiff’s attorney represented two different patients against the same physician. The attorney capitalized on the physician’s over reliance on pre-composed text in his patient records.

Records containing information from the wrong patient or inaccurate template-generated or pasted content are just some of the difficulties that can arise when using EHR efficiency tools improperly. As the following cases show, it can be difficult to defend otherwise acceptable care with problematic medical records.

Assuming an EHR automatically decreases medical record errors is risky. While some medical record errors may diminish, others that are unique to EHR use may arise. It is important to identify these potential risks and put systems in place to catch and correct errors before they cause patient injuries.

When cosmetic breast surgery performed by a physician who has not gone through formal plastic surgery training has an unintended result and a lawsuit results, the plaintiff and defendant will most likely seek the opinions of plastic surgeons on whether the defendant physician comported with the standard of care. As the following case study indicates, it can be difficult for plastic surgeons to support such surgery.

Timing must be a primary consideration when contemplating termination of treatment. To avoid abandonment, a physician must give a patient a reasonable opportunity to safely continue care with another healthcare provider. Patients with acute conditions may find it next to impossible to safely locate a new provider. For various other patients — the indigent, rural dwellers, individuals with rare conditions or combinations of conditions — it could take longer than average. Safely dismissing patients in these circumstances may take additional effort, planning and documentation.¹