If it wasn't done, don't chart it: A warning on EHR template overuse and fraud

The electronic health record (EHR) revolutionized health care documentation.

Artificial intelligence applications are further enhancing the same.

The ability to have templates in place has made recording an encounter more efficient but has usually resulted in very lengthy documents. I’ve reviewed 18- to 20-page notes from encounters with patients who had presented with a relatively minor clinical issue.

It has also increased the potential for deliberate or inadvertent fraudulent documentation.

In part of an article I authored, entitled “Bringing the EHR Into the Physician-Patient Relationship,” I reminded:

“Remember that it’s an advantage and a disadvantage for patients/families and others to easily read medical records, compared to hand-written notes from ‘the old days.’ Medicolegally, if it wasn’t recorded it wasn’t done. But the corollary is also true: If it wasn’t done, but was recorded, it’s fraud. Always make sure to delete parts of a template that were not done, not addressed, or not needed.”

Years ago, I sent my wife (who was an advanced practice registered nurse) to a surgical colleague due to a symptomatic postpartum umbilical hernia. I received the consult note, which documented a complete physical exam (PE), including a clinical breast exam. I was impressed until I reviewed the note with my wife. She noted the surgeon only asked her to pick up her shirt. “Yep,” he said. “You have an umbilical hernia. Stop at the front desk, and we’ll schedule a repair.”

No other exam, whatsoever, was performed.

I never sent another patient to him for consultation.

I’ve been a patient several times over the years and review medical records after my visits. I’m disillusioned and frankly annoyed when the note documents things that were not done.

Most recently, I had a left fourth toe ulceration and was seen by a physician who was accompanied by a third-year resident.

I wore long jeans. Only my left sock and shoe were removed to expose my left foot.

The recorded PE noted, “Left plantar fourth toe ulceration due to a hammertoe deformity.”

This sentence was accurate.

However, the documented PE also included the following: “Both lower extremities examined. No lymphadenopathy, lymphangitis or lymphedema of either lower extremity. No pain or enlargement of the lower extremity lymph nodes. The skin and subcutaneous tissues of the lower extremities were palpated and found to be of normal turgor with no induration. Popliteal, posterior tibial and dorsalis pedis arteries are palpable bilaterally. The capillary filling time is less than 3 seconds for all toes. No varicosities of either lower extremity. Reflexes are normal on both extremities. There is normal sensation on both feet with good motor function.”

None of this examination was done.

For a follow-up appointment a month later, I again wore long jeans and only my left sock and shoe were removed.

The PE noted, “Left fourth toe ulceration improved. No signs of infection.”

These two sentences were accurate.

However, the documented PE again included the following: “Both lower extremities examined. No lymphadenopathy, lymphangitis or lymphedema of either lower extremity. ...”

Again, none of this examination was done.

Some thoughts:

• I agree with the necessity to be as efficient and thorough as possible when completing encounters.
• I’m sure that signing off on unedited templates is, at times, done inadvertently. However, I lose a level of trust in those health care providers who have consistently signed off on such notes.
• The two main criteria in determining the evaluation and management code for a visit are medical decision-making and total time spent. The extent of the PE performed, for example, is not a critical factor.
• Always delete parts of a template that were not done, not addressed or not needed. In the example with my wife and the surgeon, attesting to a normal clinical exam of the breasts that was not done could have significant clinical consequences down the road.
• There’s no reason for your integrity to be questioned. A review of medical records that confirms, for example, virtually the same unedited templates, regardless of the presenting symptoms, might cause an insurance carrier, judge or jury to question a provider’s truthfulness regarding all documentation.

Our midlevel providers, residents and medical students are “watching” and may assume this is an acceptable practice.

It’s not. It’s fraud.

William Sheahan, M.D., is a family physician based in Florida who retired last year after a 40-year medical career. He earned his medical degree at the University of Virginia School of Medicine in Charlottesville and, in March 2026, received a foundational certificate in narrative-based medicine from the University of Toronto. He has enjoyed writing on various medical topics over the years. Along with clinical studies and presentations, he is the author of three volumes of “Patients Say the Darndest Things” and “A Doc Who Jots: The More You Know About Your Patient’s Story……”