Most indefensible charts come from good clinicians whose EHR — or AI scribe — made the wrong thing easy. Here are seven, and the one-line fix for each.

01Copy-forward

Yesterday’s note carried into today: a resolved problem, a line that’s no longer true, “tolerating diet” on a patient now NPO. Ambient AI does this too when it pulls in prior context.

Fix: copy structure, never findings. If a line could’ve been true yesterday, it doesn’t belong in today’s exam.

02The contradicted exam

“Abdomen soft, non-tender,” two inches above an MDM worried about appendicitis and a CT order. Now your own note argues against you.

Fix: if you’re imaging the belly, the belly exam should say why.

03The auto-normal you didn’t do

One click drops a full ten-system exam and a fourteen-system ROS on a patient you examined from the chest up. You’ve now attested to things that didn’t happen.

▼ the macro

“ROS: all systems reviewed, negative.”

▲ honest

“ROS: positive for chest pain and dyspnea per HPI; denies fever, syncope, leg swelling. Others not assessed given acuity.”

04“Return if worse”

Not a return precaution. “Worse” is a feeling to a patient and a list to you.

▼ hollow

“Return if symptoms worsen.”

▲ real

“Return right away for: worsening or moving pain, fever ≥ 100.4°F, vomiting, fainting, or new shortness of breath.”

05The silent abnormal vital

A heart rate of 118 sits in the flowsheet, never mentioned, still 118 at discharge.

Fix: address every abnormal vital in words. Explain it, treat it, or recheck it — and chart the recheck.

06The orphaned result

The potassium of 6.1 results at 03:10. Your note was signed at 02:55. Nothing says a human saw it.

Fix: re-scan results before disposition. Addend anything that landed late, and timestamp it.

07The note with no thinking in it

Every fact is there — history, exam, results — and the chart never says why. This is the gap AI scribes leave by default: they write the narrative, not the decision-making.

Fix: three sentences. What dangerous things you considered, why you ruled them down, why your disposition follows. The Workup makes it reflexive.

Educational only. Synthetic examples. Not medical or legal advice.

Seven charting pitfalls