How your documented physical exam is putting you at risk

It's 2023, and billing no longer requires you to have a certain number of bullet points for your physical exams! This should cause everyone to reconsider their use of pre-populated physical exam templates. I have recognized one big problem: they are a major source of inaccuracies. This has several consequences:

1. If these inaccuracies are used as a reference, they could lead to medical errors.

2. They are a legal risk.

3. They are used by insurance companies to deny payments.

4. The documented physical exam has become clinically unreliable.

Let's break those down:

Medical errors

Prior to 2023, doctors were using pre-populated PE templates to satisfy billing requirements. That's no longer needed, yet many still argue for their continued use.

They CAN be used properly to quickly fill in a normal physical exam that you actually did... but most are not. I will be the first to admit I'm guilty of this pre-2023. Even I was guilty of free-texting "lethargic" right next to my auto-filled "alert." facepalm I was in a rush, as we all are, and didn't double check my work.

If your physical exam is used as a baseline, it may result in a medical error. For example, if someone has baseline left hemiparesis from a prior stroke but you auto-populated normal strength bilaterally, someone may think that patient has new left sided weakness. They then may receive unnecessary head imaging...or worse, thrombolytics.

I could give 100 examples, but you get the point. Now, I know what you're thinking: "But I KNOW what's in my template. I DO double check mine."

- Well so did the person who documented no LE edema in that patient in cardiogenic shock.

- So did that cardiologist who documented regular rate and rhythm in a patient in Afib w RVR.

- So did that person who documented PERRLA on a person with an artificial eye.

Pre-populated templates are good in theory, but are filled with mistakes in practice. None of this is your fault. The system is making you see more patients than you probably should. You're in too much of a rush. So remove that variable of documenting an inaccuracy that could lead to a medical error by removing auto-filled templates and free texting / dictating your exam.

Legal Risk

The one key factor of protecting yourself in litigation is ensuring you're documenting an accurate and complete picture of the patient's condition. As I detailed above, pre-populated templates insert significant variability into that being the case.

Furthermore, if you decrease medical errors, you decrease the likelihood of lawyers ever get involved in the first place.

Insurance Denials

The pre-populated physical exam is a breeding ground for insurance denials. I help with appealing denials, so I see this on a weekly basis. Examples:

- Insurance denying payment for "respiratory failure" for a patient who had "respirations equal and unlabored" documented by every physician despite multiple respiratory rates of 30+ in the vitals.

- Insurance denying payment for "severe malnutrition" because multiple physicians documented "well-nourished" despite a patient who was clearly cachectic

- Insurance denying payment for pneumonia because no physician ever documented rales or any component of an abnormal lung exam (among other things).

Again, I could give many examples, but you get the point. Only document what is accurate. When you don't pre-populated your physical exam, it will cause you to actually THINK through that patient's exam.

Clinical Relevance

As Dr. Adam Rodman (Internist, professor, host of the Bedside Rounds Podcast) said when he retweeted my post: "I have never once trusted a templated exam in my life." I agree with him. With pre-populated templates, you cannot trust what is actually documented.

What do I recommend:

1. Use a bare template to use as a framework. My example: A sepsis template that includes: heart exam, lung exam, peripheral pulses, capillary refill, and skin exam (which is required for the sepsis bundle). These are NOT pre-populated. I use the prompts to remind myself to dictate/free text into those sections.

2. Use dot phrases (or your EMR equivalent of this) as a bare template / prompt rather than drop-down menus or box checking.

3. Free text / dictate.

I've been doing this since January 1 2023 with the new billing updates and it takes me little, if any, extra time and has actually caused me to be more thoughtful about my bedside physical exam.

That’s all for now. I hope that’s helpful.

Please feel free to reach out and ask questions as they help inspire future issues!

Cheers,

Robert

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