Medical charting

It is customary, at least in the Emergency Department, to have selective hearing of sorts. A patient says, "I have low back pain." The ER doc asks the requisite, "do you have any problems with urinary incontinence or do you ever poop on yourself?" The patient replies, "well, I have peed on myself once or twice, but not in the last few days." The physician writes down, no urinary or fecal incontinence.

This is not unreasonable, as an affirmative response to either of the questions calls for a lengthy and expensive work up, steroid administration, and possible neurosurgery or orthopedic consultation, and this patient's back pain does not seem to be related to their urinary incontinence. However, a falsehood (of omission) has now been written on this patient's chart. And this is done dozens of times, by dozens of doctors every day. For practical purposes it probably makes little to no difference. Patients receive adequate emergency care regardless of whether or not their 2/6 systolic murmur was recorded on their chart; but, if ever a chart review for research is conducted, inaccurate information is obtained. If a physician tries to find correlated physical findings he may draw an empty net, as many of the findings may have been omitted.

But I can't blame the physicians. If given the choice between omitting information on the chart and saving myself from a possible lawsuit or writing down every tiny detail for future posterity and possibly having the shoes sued off of my feet, I would omit. Because every detail on a chart must be explained. If a chart has "+ urinary incontinence" in a patient with low back pain, a physician must have a good, a very good reason for not performing an MRI. It doesn't much matter if they've had urinary incontinence for 30 years. A lawyer will pin them to the ground. And until this changes, physicians will lie.