The Risks of Pre-populated Templates
The use of electronic medical records can help physicians maintain accurate and complete documentation. The use of templates, however, may pose some risks, especially in those instances where one click can populate so much of the medical record.
In fact, through its regulatory activities, the College has seen a number of instances where the use of such a template did not accurately reflect the actual patient encounter, assessment or management plan. Concern about pre-populated templates led the College to address their use in its new Medical Records Documentation policy.
While the policy permits templates, it makes clear that pre-populated templates may pose risks to accuracy. The policy requires physicians to only use templates that allow patient encounters to be captured accurately and comprehensively, for example, templates that allow entry of free-text or that can be customized to allow for greater descriptive detail. The policy also requires physicians to verify that the entries populated using a template accurately reflect each patient encounter and that all pertinent details about the patient’s health status have been captured.
“Avoiding the use of pre-populated templates, where possible, can help ensure medical records are accurate,” states the policy’s Advice to the Profession document. “Where pre-populated templates cannot be avoided, carefully reviewing records to ensure accuracy and completeness becomes even more important and removing any information that does not reflect the current encounter, patient or their experience is vital. Inaccurate information that remains in the record may pose risks to patients, particularly if it is relied upon by other health-care providers.”