When efficiency could compromise accuracy: A closer look at EMR documentation

In brief

• Embedded Electronic Medical Records (EMRs) templates, auto-populated fields, and dictation tools can introduce clinically inaccurate information if not carefully reviewed.
• Inaccurate information saved in the medical record may negatively affect patient care and expose physicians to medico-legal risk.
• EMR tools are helpful in making the task of documentation more efficient, but it’s important for physicians and residents to actively verify that the content produced accurately reflects the patient’s encounter.

Upgraded electronic medical records (EMRs) and dictation platforms with embedded templates can reduce administrative burden, but they can also introduce a significant medico-legal risk: documentation that is clinically inaccurate.

Templates and auto-inserted fields may prepopulate findings or assessments by default. If not carefully reviewed, false or misleading clinical information can inadvertently be incorporated into the medical record. Advanced dictation tools can compound the problem when the final text is not reviewed for accuracy. Copy-and-paste habits might further spread errors that can be carried forward into subsequent notes. Once recorded, these inaccuracies become part of the clinical and legal record, potentially affecting patient care and exposing physicians to liability.

The takeaway: Documentation tools can support efficiency, but only when physicians actively review and confirm that every detail accurately reflects the encounter and medical history.

Implications for CMPA members

Documentation that appears thorough but does not accurately reflect care places physicians at medico-legal risk.  Regulatory bodies have raised concerns about medical records that rely too heavily on templates and lack patient-specific detail.

Inaccurate use of templates or copy-and-paste functions can undermine the credibility of the entire medical record, making care more difficult to defend. Even when technically accurate, over-reliance on templated content may reduce the individualized nature of clinical notes, potentially affecting their perceived reliability in medico-legal review.

Mitigation strategies

• Always review and edit templated notes. A template should be treated as a starting point, not the final product. It is important to review all autogenerated sections thoroughly.
• Educate residents and medical learners explicitly. Residents may be unaware when or how templates populate their documentation. Supervising physicians should consider reinforcing the expectation of manual review and discussing medico-legal implications during teaching sessions.
• Use copy-paste carefully. A good practice is to confirm that each copied statement remains accurate for the current encounter and to ensure that only findings that were reassessed are carried forward.
• Reduce risks in clinical settings: Documentation accuracy can be strengthened by identifying high-risk EMR templates, auditing records for accuracy and completeness, offering education on EMR use, and reinforcing clear documentation best practices.

CMPA encourages members to remain mindful of the risks and reinforce good documentation habits in all clinical settings.

More reading

• “Dictated but not read”: Unreviewed clinical record entries may pose risks
• CMPA Good practices: Transitions in care
• Electronic Records Handbook 

DISCLAIMER: This content is for general informational purposes and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. These resources are offered in accordance with CMPA's Terms of Use. AI tools may be used in limited ways, but human subject matter experts always provide oversight and final approval for all CMPA content.