EMR software uses drop-down menus to make record keeping more efficient, rather than having the physician type in free text. Such drop-down menus are often available for the physician to identify the patient’s chief complaint or presenting problem. The drop-down menu can list hundreds of potential symptoms or problems that could plague a patient. The problem arises when the menu option does not fully or precisely align with the reason for the visit.
For instance, a patient presents to a cardiologist with shortness of breath, and the physician selects “shortness of breath” from the menu. The cardiologist proceeds to work up the presenting symptom and comes to a diagnosis and treatment plan. The patient returns for a follow-up appointment and the physician again selects “shortness of breath,” or the software program may default to the last chief complaint for the patient. However, at this visit the patient does not actually have shortness of breath, as it was a follow-up appointment for those resolving symptoms. Soon thereafter, the patient has a heart attack and the cardiologist is sued for malpractice based on failing to work up “shortness of breath” at the second appointment.
At deposition, that cardiologist will be questioned about the presenting symptom of shortness of breath at the second appointment. Plaintiff will retain an expert who will hinge his/her testimony on the “fact” (as shown in the record) that the patient presented at the second appointment with shortness of breath, and that this symptom was not worked up by the physician. Consequently, the physician breached the standard of care and approximately caused the injury to the patient. That record will be used as the demonstrative exhibit at trial, and the jury may focus on this selection.
A physician can help to avoid such problems with drop-down menus by making sure the most appropriate menu item is selected. It is unfortunate, but the physician must consider the consequences of a chief complaint of “shortness of breath” in the abstract and then ask, “Is this the best selection?”
More importantly, the physician must spend time in the free text or narrative portion of the record to explain in detail the chief complaint of the patient. For example: “patient presents today for follow up on complaints of shortness of breath. Patient has no complaints at visit today of having shortness of breath.”
Plaintiffs’ attorneys can attack the quality of care based on the menu selections in EMRs. Therefore, physicians and their practices should work with software providers to explain these pitfalls and work on ways to improve the drop-down menus in an attempt to decrease liability exposures created by “one size fits all” drop-down menus.