By Bruce A. Kilgallon, CCLA, Senior Claims Manager, Coverys
Electronic health record systems (EHRs) are intended to be the most credible source for a patient’s medical information. However, there have been some bumps in the road to EHR implementation. Issues include a lack of system standardization as well as insufficient training, monitoring, or control over how EHR systems are used by healthcare providers.
Improper use of an EHR may create a challenge in defending a healthcare provider’s treatment due to a perceived carelessness in documenting a patient’s treatment. Following is information about common mistakes and advice on how to improve your use of an EHR system.
7 Common Mistakes
Most EHR systems come with detailed audit trail functions that can highlight signs of human error. Following are seven mistakes that may be highlighted:
Advice for Medical Professionals
- Choosing the wrong dropdown menu selection: Doctors may speed through the process of choosing dropdown selections which do not accurately reflect the treatment rendered to a particular patient. For example, a doctor may accidentally select the wrong gender when ordering a specific medical procedure. This is an easy mistake, and one the doctor may dismiss as insignificant. However, such a mistake could later be used as evidence that the doctor was not paying attention to the patient’s treatment plan.
- Copying and pasting: If treatment has not changed significantly, one tempting shortcut within an EHR system is the copy and paste feature. Healthcare providers should be aware that a record audit can identify the use of copy and paste occurrences. Even if the feature is not used, incidents of repetitive language could be interpreted as an indication that the doctor provided hasty or thoughtless care to a patient.
- Tailgating: When multiple healthcare providers use the same portal within an EHR system, issues may arise when providers do not log in and out of a patient’s medical record. For example, if one doctor is signed in while another doctor documents his/her treatment details, the system may not properly identify the treatment plan within the patient’s medical record. This can create confusion as to what was considered for a patient’s treatment plan.
- Delaying documentation: EHR systems provide a time stamp of when notes are entered. If a doctor does not make notes at the time of treatment, this will appear in the system’s records. Furthermore, an incorrect time stamp could result in confusion as to exactly when the treatment occurred.
- Failing to provide a detailed treatment plan: When healthcare providers heavily rely on pre-populated answers within an EHR system’s dropdown menu, they may fail to accurately describe the practitioner’s treatment plan for a patient.
- Failure to input notes into a patient’s medical record in a timely fashion: In some cases, changes occur after a patient’s visit. If subsequent information is not added to the EMR system, problems can arise. For example, suppose a general practitioner orders a prescription using the e-prescribing function of an electronic medical record system, but because the computer is temporarily unavailable, the physician issues a written prescription. However, the doctor fails to update the patient’s electronic medical record with this prescription. As a result, the system does not contain an accurate record of the treatment rendered.
- Allowing inappropriate access to a patient’s medical record: EMR systems document each time a patient record is accessed. Problems can result if someone other than a patient’s treating physician goes into his/her medical chart. For example, a physician accessing a patient’s medical record when they are no longer treating that patient, could constitute a HIPAA violation.
Electronic Health Records are here to stay so doctors, nurses and medical facilities must learn how to properly use them in their practices. Healthcare facilities must provide EHR training to doctors and the nursing staff and conversely, healthcare professionals must devote time to learning about these systems.
Although some may view the task of learning to use an EHR system as a daunting chore, their familiarity in using these systems is a necessary tool in delivering quality healthcare to patients and now, an evolving element in the defense of medical treatment decisions in medical malpractice trials.
Below are a few ways healthcare providers can improve their use of an EHR system:
- Conduct periodic audits of progress notes for a patient’s care by printing out records to compare with the record-keeping function of the EHR.
- Ensure all practitioners who are authorized to access patients’ records are familiar with the tracking features of the system.
- Train healthcare providers to understand how an EHR system records who is accessing and documenting a patient’s record.
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.