CATARACT 14 EWAP MARCH 2024 Despite best efforts, medical documentation errors happen, both on paper charts and electronic files. The consequences of some of these errors can have ranging effects on patients and the practice. From a patient standpoint, Dagny Zhu, MD, and John Bartlett, MD, shared several ways that this could affect outcomes and patient satisfaction. Steve Christensen said, “Documentation errors have the potential of creating patient mistrust, inaccurate treatment plans, coding/billing errors, and lost revenue.” “I think, unfortunately, [medical documentation errors] are relatively common,” Dr. Bartlett said, adding, however, that “most of the time documentation errors don’t have any impact on medical care, which is good.” In electronic health records, Dr. Bartlett said he thinks some of the most common errors occur from using a copy forward function. “It’s easy in most medical record systems to take a previous note and duplicate it. … People will copy a note forward, and they don’t update things like new clinical findings or the plan, so you might see there is a note from several months after cataract surgery that states Mr. Jones is doing well 1 day after cataract surgery, even though he had surgery 3 months ago,” Dr. Bartlett said. Some EHRs allow for generation of stock phrases, commonly called “dot phrases” because you use a period to invoke it, Dr. Bartlett explained. “People have standard things. They will say we talked about the risks/benefits of surgery, patient agreed to proceed, that kind of stuff. I have seen one part of the chart say one thing and a different part of the chart say something else. For example, we had a surgeon who Contact information Bartlett: bartlett@jsei.ucla.edu Christensen: stephen.christensen@hsc.utah.edu Zhu: dagny.zhu@gmail.com Learning from medical documentation errors by Liz Hillman Editorial Co - Director had a surgery where they talked with the patient about setting certain focusing with cataract surgery. The patient thought they were going to have both eyes set for near for reading. They documented that clearly in one part of the chart, but they used a stock phrase for the part of the chart that was for the plan. When they selected the lens, typically we select a lens for distance focusing, and that’s what they did, and the patient ended up with a lens focused differently than what they expected because of a The copy forward button on many EHRs as seen here makes it easy to inadvertently propagate outdated or erroneous information in medical notes. Source: John Bartlett, MD This article originally appeared in the December 2023 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp.
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