Buffing the Chart

Not long ago, medical records existed primarily to convey information between health care providers to facilitate patient care.  Times have changed, however, and medical records have become necessary for what can be viewed as a host of other equally important purposes.  Now, they are also created to avoid medical malpractice claims, to support and justify billing records, and to ensure administrative and regulatory compliance, among other things.  Unfortunately, the needs of these many competing interests do not uniformly intersect.  While the advent of electronic healthcare records has bridged some of the gap (and perhaps created its own unique problems), today’s medical chart generally will not meet all of the needs that all of the competing interests demand of it.  When this happens, the record needs to be “helped.” In medical slang, this is called “buffing the chart.”

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The term was brought to public attention by Stephen Bergman, M.D., a psychiatrist and author of the novel The House of God, a satirical look at the underbelly of the medical profession.  Buffing the chart occurs when information is entered in the record which was not stated by the patient, not seen in an exam, not documented in a procedure, or is simply not true.  The term buffing the chart captures a variety of conduct that is intended to sway a reader in a particular direction.

The “late entry” is one I frequently see in my practice.  This often occurs after a bad outcome when the health care provider knows the record is likely to be closely scrutinized. Altering the chart, besides being entirely unethical, is also becoming increasingly difficult with our ability to alalyze meta data in the electronic medical record.  The late entry generally provides CYA information, imagined or real, intended to support the health care provider’s decision making and conduct.  For example, when a patient dies of a heart attack not long after presenting to an emergency department with left-sided chest pain, the chart might be buffed to suggest that stable angina, a low risk condition not likely to result in death, was the best diagnosis.

Charting examinations that did not occur is a way to increase the level of care reported and, therefore, the amount that can be billed is another example.  The electronic healthcare record, with its templates and drop down menus, helps with this.  For example, a genital or rectal exam may be charted with the click of a mouse as one of a host of options that is routinely populated on a check the box computer template when someone appears in the ER with cold symptoms.  A click of the mouse equals the ring of the register. Rarely will a genital exam be done for a cold, but it often appears in records when it has not.

Another example is when hospital administrators tasked with reviewing medical records for completeness and accuracy notice missing information.  They might later ask a physician or nurse to recall something about a patient’s care to ensure regulatory compliance. The pressure to “remember” something that happened with a single patient a long time ago can be extreme, especially when the person asking may have the power to negatively report the performance the health care provider who has already failed to make a complete record.

My clients tell me all the time that information I see in their medical records is inaccurate, and I believe them.  It’s a problem, especially because jurors tend to believe that  records, and not the patient, when it comes to what they felt like, what they said, and what was done to them and when.  These problems can be overcome, but it can be difficult and painstaking.  So, the next time you get medical care, you might want to take a look at the records to see what’s in there.  Your rights as a patient allow you to challenge inaccuracies you find including those that might be the result of buffing the chart.  I’ll write about how to do that next time.

Posted in medical charts, medical errors, medical ethics |