What makes a normal ENT exam normal? Is the absence of tonsils worth noting? A bifid uvula? It depends. What does the template include in its definition of normal? More importantly, does the physician remember or did he ever know what his computer considers normal? With a single mouse click, he can create a crisp, laser-printable document that because of its legibility and level of detail appears to be the gospel truth.
But of course, sometimes and certainly too often, it’s not the truth. I recently received an e-mail from a pediatrician who said that he files the EHR records from specialists, emergency departments, and urgent care centers in the "fiction section." He cited an example of a report from a neurologist about a 10-month-old that included a "normal sense of smell" and a warning against driving while taking the medicine prescribed. I can’t top that; maybe you can. But I certainly have received numerous reports that clearly bore little relationship to what had transpired in the clinic or specialist’s office – complete neurologic exams that would have taken 30 minutes to perform, normal tympanic membranes in children with PE (pressure equalization) tubes or cavernous perforations.
Although I frequently complain about the sad state of the physical examination, a bigger problem may be the reliance on the EHR to document the result of the exam. I fear there is little incentive to correct the problem because of the malpractice lawyers’ mantra, "if you didn’t document it, it wasn’t done." Unfortunately, that has come to mean that if it’s legible and detailed, it must be the truth. I would enjoy hearing from you some examples in which you know this clearly wasn’t the case.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including "How to Say No to Your Toddler." E-mail him at pdnews@frontlinemedcom.com.