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June • 10 • 2021

Electronic Health Records: Documentation Pitfalls


By Ginny Adams, RN, BSN, MPH, CPHRM; Jennifer Garcia, Esq.



The potential of the electronic health record (EHR) to improve patient care and safety was a major impetus in its adoption. Poor documentation in the EHR can affect patient care and outcomes and increase potential practitioner liability.

The potential of the electronic health record (EHR) to improve patient care and safety was a major impetus in its adoption. However, studies on how EHRs impact the processes and outcomes of care have generated mixed results. While the EHR provides a platform for comprehensive management of medical information and secure exchange between practitioners and healthcare consumers, its theoretical safety and quality benefits are blunted by limitations in design, adoption, and use.1

Poor documentation in the EHR can affect patient care and outcomes and increase potential practitioner liability. Consider the following cases: 

Case 1 - Failure to understand EHR functions

Facts: A 52-year-old patient sees his primary care practitioner in 2016 for an annual well visit and reports intermittent abdominal pain due to constipation. During this visit, the practitioner adds “abdominal pain” to the patient’s problem list in the EHR. Appropriate medical interventions alleviate his symptoms. The patient returns in 2019, reports severe right upper quadrant pain, and ultimately receives a diagnosis of advanced pancreatic cancer. The patient’s attorney requests an EHR review and discovers that the printed version of the electronic record includes abdominal pain in the problem list for every encounter between the 2016 well visit and the eventual diagnosis, even though the patient did not report abdominal pain during any of those visits. In the resulting litigation, the plaintiff’s attorney questions the documentation’s accuracy. The physician admits that the documentation was incorrect because he didn’t know how the system worked. 

Issue: The problem list, a universal design feature in the EHR, can be a source of current and comprehensive patient information and a powerful tool for clinical decision-making. However, without proper structure and oversight, it can also be a source of confusion or error. Associated concerns are as much related to process, policy, and accountability as they are to software system design and development. In this case, the problem list functioned as intended, but its usage introduced the potential for inaccurate patient assessment and care.

Regardless of how well an EHR is designed and adopted, usability is critical. The International Organization for Standardization defines usability as “the extent to which a system, product or service can be used by specified users to achieve specified goals with effectiveness, efficiency and satisfaction in a specified context of use.” Simply put, usability refers to how well a product supports the end user’s work. If usability is an issue, workarounds and/or lack of compliance are frequent outcomes.

Case 2 - Failure to utilize EHR safety features

Facts: A 47-year-old patient has an incidental finding on a radiology study. The radiologist recommends repeating the study in six months. The ordering physician notes that the patient has been notified of the need for this repeat study. When the patient returns nine months later, the physician fails to order the repeat study and does not document a follow-up conversation about the study with the patient. Two years later, the patient receives a progression of disease diagnosis. A subsequent lawsuit alleges physician negligence due to the lack of an adequate reminder system for follow-up testing. An investigation reveals that the physician’s EHR had the capacity to generate reminders about the need for future testing, but the physician and staff were not aware of the system’s capacity to do so.

Issue: Clinical decision support (CDS) refers to information or tools to help practitioners manage actionable information to support decision-making at the point of care. In this case, a reminder to order a repeat radiology study is a CDS tool. The EHR had the capacity to deliver a reminder; a process to utilize that feature was not adopted for use. 

The effect of EHRs on patient information collection

In order to benefit from the EHR’s full potential, healthcare organizations should consider redesigning workflows to utilize available features, optimize processes, and clearly define practitioner roles. 

One outcome of the transition to EHRs has been a shift in how practitioners gather patient information. Patient assessment, examination, and verbal communication are time-honored sources of that information. Research now shows that the collection of patient information is “the one area that has suffered the most with the infiltration of technology into the workflow. Specifically, it is estimated that physicians now spend more time on a computer in the review and documentation of patient findings than they spend with the patients.” This can create an overreliance on others’ record entries. It is imperative that practitioners do their own clinical assessment and not rely solely on other documentation.

Changes to technology and the processes for electronic/human interface in providing and documenting care should be broad and innovative, focusing on the six aims for the healthcare system: safe, effective, patient-centered, timely, efficient, and equitable care. These changes should address both technical and social factors. Organizational culture will significantly impact the eventual success of these changes and the end result of safe, quality care that is accurately and comprehensively reflected in the EHR. The Joint Commission’s March 2015 Sentinel Event Alert on safe use of health information technology suggests that organizations implement actions centered on three crucial areas: safety culture, process improvement, and leadership. 
Risk Recommendations

It is easy to appreciate the medical record’s role in malpractice litigation and the EHR’s need to accurately reflect practitioner findings. A surprising number of EHR-related medical malpractice claims could be avoided by comprehensively reviewing system capabilities and limitations. When reviewing your EHR system, consider the following:
  • Ensure the ability to set reminders for practitioners and staff, such as need for follow-up labs, routine testing, and issues to address during future visits. 
  • Assess the ability to communicate between practitioners and staff.
  • Check the process to edit the current medication list.
  • Confirm the capability to auto-populate information, such as medical history and problem lists, to future visits. If the EHR system does have that capability, learn how to modify that information. 
  • Ensure the ability to document telephone calls and nontraditional patient encounters.
  • Test print the medical record on paper to assess whether to change auto-populate or default settings to reflect the practitioner’s intent and preference. Consider whether your documentation could lead another practitioner to understand what you did and why.
  • Provide additional training for all users, even if the EHR has been in service for many years.
EHRs introduce new kinds of risk into an already complex healthcare environment. A practitioner’s EHR use can lead to allegations of professional liability. Defensible cases in which the practitioner delivered seemingly excellent care have been lost or settled because of poor EHR documentation. The most powerful strategy for defending a lawsuit or administrative action is accurately documenting the basis for clinical decision-making. The EHR can support this type of documentation if attention is given to the appropriate design, adoption, and use of that record.
  1. Agency for Healthcare Research and Quality. Patient Safety Primer: Electronic Health Records. Patient Safety Network. Updated September 2018. Accessed April 27, 2021. 
Copyrighted. No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances. 



  • Risk Management & Patient Safety