Dear Dr. Helfgott:
Thank you for your thoughtful article on medical records. To expand on the issue of “templates,” the biggest problem in my view is that the original purpose of the medical record (documenting true and accurate clinical observations for present care and for future reference) has now been subverted because billing is dependent on the length and content of the notes. It is largely the pressure to bill at maximal rates that leads to the excess (and usually inaccurate) verbiage. Who now really believes most observations recorded in templated or cloned medical notes? How many times do we now read, for example, that the musculoskeletal exam was normal, only to observe that the patient has multiple deformities and extensive synovitis? As in science, medicine depends on honest and accurate observation, and not on confabulation of findings. This problem has serious implications for patient care, and for our integrity as physicians.
Philip L. Cohen, MD
Professor of Medicine
Chief of Rheumatology
Temple University School of Medicine