Prepopulated templates are often suggested as a potential time-saver when entering clinical data into the Emergency Medical Record (EMR). It is important to recognize that these may pose a risk to accuracy and integrity of clinical data.
The CPSS Bylaw 23.1 sets out the expectations for Medical Records. While the prepopulated templates may make the record look more complete and adherent to the requirements of the College’s bylaw or for billing purposes, there is an inherent danger that, when not carefully reviewed, it may reflect inaccurate or unreliable information.
This applies to prepopulated templates, copy-and-paste (cloned) notes, acronym expansions, and auto-populate functions in the EMR.
For example, a patient attends for a sore throat, and the prepopulated template contains elements such as “Vitals stable”, “No pallor or jaundice”, or “Neurovascularly intact”; these are unlikely to be assessed at such a visit. If not assessed during the visit but still contained in the EMR note, this can be viewed as misleading or erroneous charting. From a medicolegal perspective, such chart notes can potentially lead to action by the College.
Some templates may not be suitable to the reason for which the patient is being seen, potentially failing to accurately reflect the clinical status or contain only certain elements which are inadequate to describe the complexity of the patient’s condition.
There are templates that are suggested for use specific to the patient’s complaint (e.g., backache template, full physical template, sore throat etc.) that may limit the provider to record additional information by the design of the specific template.
Sometimes it may seem like a good option to copy and paste the previous visit note to avoid the need to enter some clinical information. This may lead to errors in perpetuating incorrect or outdated information. It also may lead to unnecessary redundancy, in which the essential information may get lost.
If an audit is performed on the notes, for example by the Practice Enhancement Program (PEP) or by the JMPRC, and every note looks the same, it will raise a red flag about whether the care was actually provided as described. Common documentation risks with copy-and-paste or cloning include features such as vital signs that never change from one visit to the next, pronouns used incorrectly, such as “he” instead of “she”, a statement that the patient is not anemic when the lab results indicate the contrary etc.
In some templates there may be multiple checkboxes and dropdown menus to facilitate completeness, and this may lead to the so called “Alert Fatigue Syndrome”, similar to what is described as “Alarm fatigue” (frequent alarms, many of which are avoidable, can lead to inadequate responses, impacting patient safety). It is described as “data overload” and “template noise” in some articles.
There is a difference between prepopulated and care-facilitating templates. A well designed template (for example the Chronic Disease Management or CDM QIP flowsheets, and the Saskatchewan Prenatal Record, both of which are incorporated in the EMR ) may facilitate quality of care – and both of these are templates that import relevant previous data, rather than prepopulating the clinical findings for the current visit.
Ensure the integrity of the patient record when using prepopulated templates, to make sure that only the relevant clinical information is accurately reflected, and that incorrect auto-generated entries are deleted or amended.
The CMPA has a short document on tips to improve electronic records, and point (4) speaks to template use.