A known problem with electronic medical records is the use of template-based documentation.
This saves a tremendous amount of time, as paragraphs upon paragraphs of information can be documented with a single keystroke.
Problems arise when doctors, inadvertently or not, document history or physical exam findings that do not exist. The issue occurs more often than you think, and with the traditional mindset of “if you didn’t document it, it didn’t happen,” does the opposite extreme hold water?
Or, as #1 Dinosaur writes, “It seems that more and more doctors are taking that to mean that if something IS documented, then whether or not it actually happened is moot, at least as far as payment is concerned.”
Should doctors, who know of others who fraudulently document, blow the whistle, or issue a more subtle warning to the offending physician?