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Tuesday, February 08, 2022

Phantom physical exam reports continue to proliferate in the strange world of the electronic health record

 Recently,I learned that nurse practitioners as well as physicians are authorized to post  the results of physical exams that were not done in the medical record (EHR) 

The narrative of the encounter  I had with NP was accurate and fairly detailed and I actually learned a lot about how the thousands of remote device interrogation are reviewed in their department.

 Although one of the reasons for the visit was to check the surgical wound (I had a pacemaker replacement one week before) there was no mention of that in the EHR report of the encounter although the NP did glance at the surgical site.  I was described as having no edema and having normal pulses but those findings were fictional. A similar fictional physical exam was detailed in the pre op visit one week earlier with the EP cardiologist. (Actually I do have a trace of ankle edema at the end of the day and my posterior tibial artery is very hard to palpate.)

When I attended medical school in an earlier century my teachers emphasized the importance of transcribing a physical exam and other clinical findings as accurately as possible and that the medical record was a legal record and could be subpoenaed. The medical record is the basic legal document in medical malpractice litigation. 

Why would a bogus physical exam description be routinely inserted into the EHR as that occurrence appears to be the case. If it is done to be able to "upcode" the record why would the practice not be fraud?

Other than an intent to defraud, what else could explain the profusion of bogus system reviews and physical exams. Simply put it may be a unintended consequence of the EHR and the quality movement, Standard boiler plate material is generated by the EHR to fill the need to comply with the increased demand for documentation of "quality "clinical work. The alleged intent was to have clinicians edit out activities not performed.However,that has not been the outcome as through inattention or in some cases perhaps intent the fictitious exams remain displayed in medical records awaiting a plaintiff lawyer to ask Dr. Did you perform a physical exam on a certain date?

addendum: 3-15-2022 I learned from someone knowable in current Medicare charges and EHR vagaries that Medicare no longer pays more if a physical exam is performed and charges are earned based on time spent and case complexity. So there would be no monetary advantage to charting a physical exam or system review but the phantom exams seem to still be appearing in EHRs.

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