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The 47 Documentation Failure Modes
On this page1 to 6 Fabrication · 7 to 11 Omission · 12 to 16 Attribution and certainty · 17 to 21 Identity, PHI and the persistent record · 22 to 27 Numbers, units, sides and soundalikes · 28 to 32 Structure and template · 33 to 37 Verification and signature · 38 to 42 Workflow and handoff · 43 to 47 Patient-facing language · What it is for
A catalogue of the ways AI-assisted clinical documentation goes wrong: notes, portal replies, discharge instructions, prior authorization letters and handoffs drafted with a general purpose model or an ambient scribe. I collected them from drafts I reviewed on service. It is for US physicians who sign what these tools produce. Each entry names the failure, its mechanism, a check you can run before signing, most of them in under a minute, and the habit that prevents it. Read it once, then keep it beside the draft. Educational material, not clinical or legal advice.
MODE 01 · THE INVENTED EXAM FINDING · NOTE EXCERPT
Draft returned for your reviewdermatology follow-up, rash
O: Skin: [AS EXAMINED]
Neuro: cranial nerves intact, reflexes symmetric no reflex hammer was picked up