The chart is complete. Every required field is filled out. The dropdowns are selected, the template is populated, and the note is signed.
But can the next clinician understand what happened?
That is the question we should be asking before we call documentation complete. A record can satisfy every electronic requirement and still fail to explain the patient’s condition, the clinician’s concerns, or the reasoning behind a decision. When that happens, the problem follows the patient. It can surface during a handoff, a coding review, a denial, a quality investigation, or years later in a courtroom.
We have made it easier to enter information, but often not done the same to understand the care.
A Selection Does Not Explain a Decision
Checkboxes and dropdowns have a legitimate place in the medical record. They standardize terminology, organize assessments, and make information easier to retrieve. The problem begins when the selection becomes the entire explanation.
“Normal” tells us what was selected. It may tell us very little about what was assessed. “Stable” may describe a patient whose condition remains serious, but unchanged. “No” may reflect a narrowly worded screening question, rather than the absence of a broader concern. Without context, the next reader must supply meaning that the author never actually documented.
Consider an illustrative discharge note that reads only “stable for discharge.” Stable compared with when? What improved? What concerns remained? Why was the next setting appropriate? Who would follow up on the unresolved issue? The checkbox may accurately reflect the clinician’s conclusion, but it cannot by itself answer those questions.
This is where documentation integrity becomes more than completion. The record must connect the assessment to the decision. When it does not, readers must reconstruct the care from disconnected pieces, and they may reach different conclusions.
When the Record Has to Speak for Itself
In Lindsay Clancy’s trial, psychiatrist Jennifer Tufts said “I don’t care what it says. I know what I meant.”
That disagreement illustrates a documentation problem: words and selections can appear clear to their author while leaving another reader uncertain. It does not establish that a checkbox caused harm, but it does remind us to reconcile the narrative with the structured fields before signing.
The author carries the memory of the encounter. The next clinician does not. Neither does the coder, the auditor, or the person reviewing a complaint. They have the words and selections that remain. An explanation offered years later cannot help the clinician who needed the information the next morning.
The civil complaints related to this matter bring the communication issue closer to clinical practice. Patrick Clancy’s complaint alleges a responsibility to document psychiatric assessments, so other care team members could understand them. Lindsay Clancy’s complaint raises concerns about assessment, treatment, and care coordination. These are allegations, not malpractice findings. They identify questions a record may have to answer: What was known? What was considered? What was communicated? Why was that plan chosen?
Those questions have mattered in decided cases. In Jablonski by Pahls v. United States, the Ninth Circuit affirmed a malpractice judgment involving failures to obtain prior psychiatric records and to record and communicate a police warning. The court upheld findings that these omissions contributed to the victim’s death.
Jablonski predates electronic templates. Its relevance here is the role of information in care: a completed assessment cannot compensate for critical context that never reaches the person making the decision. For today’s clinician, that means preserving the observations, outside reports, and unresolved concerns that a yes-or-no selection cannot adequately express.
What Disappears Between the Boxes
Clinical reasoning is often the first thing lost when a template becomes the note. A diagnosis may appear without the observations supporting it. A medication change may appear without the reason for the change. A negative screen may appear without the history that made the clinician continue asking questions.
The distinction matters. A patient’s denial of a current symptom, a clinician’s observation, and information supplied by a family member are different kinds of evidence. Compressing them into one selection can erase those differences. Good documentation preserves the source, the timing, and the interpretation of information that affects care.
For example, “patient denies shortness of breath” is not interchangeable with “respiratory status normal.” One reports what the patient said; the other implies an assessment. If the examination identifies concerning findings, the record needs to explain them – and the response. A reassuring selection should not obscure an abnormal observation elsewhere in the chart.
The same concern applies to change over time. A patient may look better during a brief encounter while important concerns remain unresolved. Documentation should explain what improved, what did not, and how both influenced the plan. A series of isolated selections cannot reliably carry that story forward.
A Shortcut Can Carry an Error Forward
Templates also create opportunities for information to persist after it stops being accurate. A normal finding may remain selected. A prior examination may be copied into today’s note. A dropdown may force a choice that does not adequately describe the clinical situation.
The Centers for Medicare & Medicaid Services (CMS) has warned that macros, templates, and cloned documentation can introduce errors and fail to provide the patient-specific information needed to support services. A systematic review likewise identifies risks from copy-and-paste practices, including inaccurate or outdated information.
The danger is not limited to an obviously incorrect sentence. Repetition can make an entry appear confirmed. Several notes may contain the same finding because each inherited it from the last, rather than because several clinicians assessed it independently. A later reader may not be able to tell the difference.
For clinical documentation integrity (CDI), this creates a familiar problem: a diagnosis or indicator appears in the record, but its meaning and support are uncertain. Coding may need clarification. Quality reviewers may interpret timing or causation differently. A payer may question whether the documentation supports the service. The more consequential the selection, the more important it is that the record explains what it represents.
More Words Will not Fix Missing Meaning
The answer is not to replace every checkbox with a paragraph. Long notes can conceal important information just as effectively as short ones. Copying additional history into an assessment does not show that the history influenced the decision.
We need a purposeful narrative wherein a selection cannot carry the clinical meaning.
A useful assessment connects the relevant findings, the clinician’s interpretation, and the plan. It explains uncertainty when uncertainty affects management. When findings conflict, it addresses the conflict. When a plan changes, it states why. AHRQ’s discussion of copied and autopopulated documentation emphasizes the importance of making the patient’s course and the clinician’s thinking understandable to later readers.
Sometimes, a few sentences are enough. Explain why a concerning finding did not change the disposition. Identify the reported adverse effect that prompted a medication change. State which issue remains unresolved and who will reassess it. Those details give the next person something a completed field cannot provide: a reasoned account of the care.
Completion Should Not Be Our Only Measure
Organizations help create this problem when their documentation expectations focus primarily on required fields and timely signatures. Those measures matter, but do not establish that a note is useful.
The technology itself also requires scrutiny. In 2017, eClinicalWorks and certain employees agreed to a $155 million settlement resolving False Claims Act allegations concerning software capabilities and kickbacks. Alleged deficiencies included inaccurate audit logs and unreliable recording of some diagnostic imaging orders. The settlement did not determine liability.
That case concerned software integrity, not a finding that checkboxes caused malpractice. For documentation leaders, it reinforces a related responsibility: assess whether the system faithfully preserves and communicates clinical work. A signed note is only useful if the information it contains can be trusted.
CDI can help move the conversation toward meaning. Can another clinician understand the assessment without asking the author what was intended? Does the narrative agree with the structured fields? Is the information current? Can the reader distinguish a patient report from an observed finding? Does the plan identify who is responsible for follow-up?
Template governance should include those questions. Clinical leaders, informatics, health information management (HIM), quality, and CDI should examine where defaults, limited choices, and copied content create ambiguity. Education should show clinicians how a few well-placed sentences can preserve reasoning. Audits should look for contradictions and unsupported statements, not simply empty fields.
This responsibility also extends to artificial intelligence (AI)-assisted notes. Fluent prose can still omit a qualifier, import an outdated finding, or make an uncertain conclusion sound definite. Whether the content began with a checkbox, a macro, or generated text, the clinician must verify that the signed record accurately represents the encounter.
The most important reader may arrive long after the author has left the room. That reader should not have to guess what “normal” meant, why “stable” was selected, or whether a copied finding was reassessed.
A completed template can show that the fields were filled in. The medical record must show the care that actually occurred – and the reasoning that made it appropriate.
References
- Schooley M, Kmitt P. Lindsay Clancy’s psychiatrist Jennifer Tufts completes testimony at murder trial with tense exchange. CBS News. Published August 11, 2026. Accessed September 12, 2026. https://www.cbsnews.com/boston/news/lindsay-clancy-trial-watch-live-day-10-jennifer-tufts/
- Clancy PW. Complaint and jury demand. Clancy v Tufts, No. 2682CV00071 (Mass Super Ct, Norfolk County). Filed January 20, 2026; docketed January 21, 2026. Paragraph 62. Accessed September 9, 2026. https://media.nbcboston.com/2026/01/Patrick-Clancy-Civil-Suit.pdf
- Clancy LM. First amended complaint and jury demand. Clancy v Tufts, No. 2682CV00081 (Mass Super Ct, Norfolk County). Filed January 27, 2026. Accessed September 9, 2026. https://static.foxnews.com/foxnews.com/content/uploads/2026/07/Clancy-Civil-Lawsuit.pdf
- Jablonski by Pahls v United States, 712 F2d 391 (9th Cir 1983). Accessed September 12, 2026. https://openjurist.org/712/f2d/391
- Centers for Medicare & Medicaid Services. Documentation integrity in electronic health records. Published June 2016. Accessed September 9, 2026. https://www.cms.gov/files/document/ehrdocumentationfs062816pdf
- Centers for Medicare & Medicaid Services. Ensuring proper use of electronic health record features and capabilities. Published June 2016. Accessed September 9, 2026. https://www.cms.gov/files/document/ehrdecisiontable062816pdf
- Tsou AY, Lehmann CU, Michel J, Solomon R, Possanza L, Gandhi T. Safe practices for copy and paste in the EHR: systematic review, recommendations, and novel model for health IT collaboration. Appl Clin Inform. 2017;8(1):12-34. Accessed September 9, 2026. https://pubmed.ncbi.nlm.nih.gov/28074211/
- MacDonald S. “Copy and paste” notes and autopopulated text in the electronic health record. PSNet. Agency for Healthcare Research and Quality. Published 2023. Accessed September 9, 2026. https://psnet.ahrq.gov/web-mm/copy-and-paste-notes-and-autopopulated-text-electronic-health-record
- U.S. Department of Justice. Electronic health records vendor to pay $155 million to settle False Claims Act allegations. Published May 31, 2017. Accessed September 12, 2026. https://www.justice.gov/archives/opa/pr/electronic-health-records-vendor-pay-155-million-settle-false-claims-act-allegations
