Females Shouldn't Have Male Genital Discharge - A Lesson on Macros in Charting

Years ago, I had a bright, efficient resident who was very adept at using macros in his charts. His charting looked complete and detailed at first glance. I had made it a habit to skim through each section of each resident’s note to make sure the gist of the patient’s story was complete to the best of our understanding. I thought I would not have to worry about this resident.

Then while skimming a chart I saw this for a female patient: “penile discharge – negative”

I went to him and talked to him about it. He’d been using the same macro on all his patients and then customizing them. I told him he should be more careful. We had a talk about having his chart internally consistent and why internal consistency made his chart more credible… and how a more credible chart means a more credible doctor.

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Imagine if you had a chart with an assault victim, you mentioned bruising in the HPI and you forgot to adjust your macro ROS and it still said “no bruising”. The following questions would likely pop up:

·         Which part should your reader believe?
·         Would your chart be believable at all?
·         Would you look sloppy?
·         Would you seem believable? 
 

Now imagine that hypothetical chart in an M &M conference, at a deposition, or in a court. Suddenly your oversight makes you look real bad.

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I think macros are fine tools. However, you have to be careful using them. Macros can certainly speed you up, especially when it’s busy and your charting system is slow. However, if you’re not careful they can hurt you. A power saw is a good example of such a tool. It cuts fast, but can cut you badly if you’re careless. 

Be careful when using a power saw and be careful when using macros. Both can hurt you when you’re not paying attention.

If you are interested in learning more about medical charting, please check out my book: The Handbook of Medical Charting