WNL: ‘Within Normal Limits’ or ‘We Never Listened’?

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March 1, 2014 Volume 78, Number 3
WNL: ‘Within Normal Limits’ or ‘We Never Listened’? Wendy B. Kang, M.D., J.D.
Committee on Ethics

An octogenarian with a broken hip arrived in preop holding. She was hyperventilating, moaning that she could not breathe. After I quickly applied oxygen and reassurance, a focused physical exam revealed no râles, but a grade 4/6 harsh systolic murmur suggestive of aortic stenosis. I anxiously awaited the agonizingly slow awakening of the computer to access her electronic medical records (EMRs). The medicine resident’s daily notes and cardiology consult all indicated RRR but did not mention any murmurs. Thinking this was a new onset cardiac murmur, my resident telephoned the medicine resident who stated: “Oh, yeah, she’s had a murmur; nothing new.” A quick refresh of the computer screen on my end noted that the medicine resident had changed her latest progress note to indicate there was now a heart murmur. She might have covered her tracks, but all her previous notes and the cardiology consult still mentioned no heart murmurs.


Several issues popped into my mind. Are we under the delusion that EMR can delete our deficiencies in physical exams to create totally different patients? Was the medicine resident really being truthful? Had she put her stethoscope to the patient’s chest and engaged her analytical mind in the interpretation of heart sounds? Did she type “Regular Rate and Rhythm” (RRR) because of other pressing clinical concerns? Was the initial lapse in proper documentation of a critical physical finding then perpetuated via a daily reflexive copy and paste – on her part and that of a subsequent cardiology fellow? Were the progress notes on the EMR trustworthy? Could I rely upon them in taking care of my sick patient?


Accurate medical records promote quality patient care. Physicians promote the usefulness of medical records by documenting as accurately as possible the patient’s history and physical exam findings. Laboratory and radiological studies are included to assist in our arriving at logical diagnoses upon which the treatment plans are devised. Medical records are useful when physicians desist from the inappropriate temptation to alter them. Altered records make them suspect. Alterations also cast doubt on the physician’s professionalism and credibility.


The medical record, whether paper or electronic, is a legal record and should be treated with the gravity such a document deserves. It used to be near-impossible to change paper documentation without some obvious trace. One marked through the original entry with a single line and initialed the strikethrough. A note titled “Addendum” or “Late Entry” with appropriate new date, time and explanatory information would then be added at the bottom of the progress notes. None of the previous entries by other health care providers in their context to the original note would have been removed. This preserved the integrity of the medical records as well as the progression of thoughts and therapies.


EMRs have increased legibility. Unfortunately, with the ease of cut, paste, delete and insert, EMRs have also increased changeability. Digital progress notes started in the morning can possess startlingly different conclusions by their completion in the afternoon. Pages of vital signs and labs pasted from other sections of the EMR clutter the progress notes. Pithy assessments by physicians as to the true progress of the patient’s health are hard to find. Even when found, who is to say they will not have changed with a simple refreshing of the computer screen?


Physicians must be aware that digital changes can be scrutinized. Electronic footprints do exist. Types of deletions and insertions along with times and authors are embedded digitally. Invisible on the computer screen, forensic sleuthing by a legitimate computer expert can reveal all changes to interested parties, including malpractice attorneys. Possible criminal or civil liabilities for altering medical records – paper or electronic – exist. There are now legal cases, such as in Pennsylvania, where family members are alleging alterations in EMR of deceased patients.1 Seemingly innocent touchups of the medical records could turn a defensible case into one that must be settled.


Under the current health care climate, EMRs are here and staying put. Physicians have means to protect themselves from allegations of tampering with EMRs. Physicians must ensure that software programs automatically date and time all entries. While tiresome to log off and back in, records that automatically lock in all entries can protect the veracity of the patient medical records from indiscriminate additions or deletions by poseurs. The EMR software should also be capable of tracking changes.2


Are making changes to EMRs acceptable? Probably yes, when these changes are correcting, modifying or appending during the contemporary course of patient treatment. But after an unexpected adverse outcome or legal notice of a claim, the answer is NEVER. Such changes may be construed as a deliberate misrepresentation of facts or even destruction or concealment of evidence, i.e., “spoliation.” Altering medical records with the intent to deceive may result in civil and even criminal liability. Many states such as New Jersey consider “the purposeful destruction, alteration or falsification of records relating to the care of medical, surgical or podiatric patients in order to deceive or mislead is a crime of the fourth degree.”3


In addition to a claim of medical negligence, the patient/plaintiff may assert a separate claim for fraudulent concealment against the physician. Punitive damages are usually triple the compensatory monetary awards. Many medical malpractice policies exclude coverage for claims in which medical records have been altered. The physician might end up paying for exorbitant judgment and legal costs out of personal assets.


The anesthesia record exists as the anesthesiologist’s sole indication of the professional care rendered to the patient. It must be detailed and accurate to guide future anesthetic care when the patient returns to the operating room for other surgical interventions. It can serve as our best friend in a legal setting where fuzzy memories and words can be twisted. If they are of any other nature besides truthful and accurate, those records become a sword against us.


Returning back to my quandary as to the trustworthiness of the EMR, I also wondered whether this octogenarian had been informed about her heart murmur. “WNL” is commonly written in health care to signify “within normal limits.” It is doubtful that my patient was ever WNL if she had a heart murmur that could be easily heard, even without a stethoscope. Did any physician demonstrate any ethical considerations to the patient by explaining her conditions?


Studies have shown that the vast majority of patients want to know about their conditions.4 Study participants (99 percent) thought that physicians had an obligation to inform patients of their condition and would want to be told if they had a life-threatening illness (97 percent).


There is a direct correlation between age, income and amount of education and the amount of information patients desire from their physicians. My stabilized elderly patient and her daughter were informed about the heart murmur and the need for further assessment prior to surgery later in the day.


As physicians, WNL should stand for “within normal limits” because we do examine our patients and we do listen to their concerns. Ethically, WNL stands for “we never lie” – neither to the patient nor on the medical records. There are rare exceptions, but only for patients’ best interests. Patients should be heard, examined, and given clear explanations about their health status and treatment options. The medical record – whether paper or electronic – serves as a health and legal document attesting to the physician’s capable care of the patient and to the discussion about treatment course and plans. Honesty to our patients and our colleagues uphold the professionalism that is so vital to our conduct as ethical physicians.5 These behaviors are “within the normal limits” of our profession.  

Wendy B. Kang, M.D., J.D. is Professor of Clinical Anesthesiology, Department of Anesthesiology, University of Texas Health Science Center at San Antonio. 


1. Hamil SD. Trial to begin in wrongful death claim. Pittsburgh Post-Gazette. September 19, 2011. http://www.post-gazette.com/health/2011/09/19/Trial-to-begin-in-wrongful-death-claim/stories/201109190243. Accessed January 13, 2014.

2. Sheber S. New toolkit provides guidelines for EHR amendments. Journal of AHIMA website. http://journal.ahima.org/2012/08/29/new-toolkit-provides-guidelines-for-ehr-amendments/. Published August 29, 2012. Accessed January 13, 2014.

3. N. J. Stat Title C2 §21-4.1.

4. Sullivan RJ, Menapace LW, White RM. Truth-telling and patient diagnoses. J Med Ethics. 2001;27(3):192-197.

5. Kirk LM. Professionalism in medicine: definitions and considerations for teaching. Proc (Bayl Univ Med Cent). 2007;20(1):13-16.