Tailoring the Chart

To the Editor: I share the concerns expressed by Drs. Dwyer and Shih both for preserving social trust and for taking a long-term view of practice decisions that can impact not only on the individual in treatment but also on the system of care. Readers who are interested in looking at the issue from a somewhat different angle might want to read discussions by Garfinkle (1) and Ginsberg (2). They will find that selective recording practices are not a new phenomenon bred by the managed care environment, but a persistent problem in need of continued monitoring.

While it is (sadly) the case that some few practitioners construct patient records with the intent to defraud, it is my belief that most are concerned with the well-being of the persons under their care. Assuring that the patient's treatment needs are met, that maximum insurance coverage and minimal out-of-pocket expenses occur, and that the patient is protected from stigma are three short-term "good" reasons for making charting decisions of the kind noted by Dwyer and Shih, Garfinkle, and Ginsberg.

From this point of view, distortions in records are the result of short-sighted adaptations to the care environment and changes in that environment. To the extent that remediation is possible, the problem must be acknowledged by both payers and providers. Providers need to be reminded to take the long view of their charting behaviors. Payers and, for that matter, accrediting bodies must learn to anticipate the effects of their data demands on providers. This last is particularly urgent, as it is the providers' professionalism and expertise on which accrediting bodies ultimately depend.