With electronic medical records, make these charting changes, and make the record defensible
An ear, nose, and throat examination might not be necessary for a patient presenting with right-sided chest pain, but if the electronic medical record’s (EMR’s) screen is left blank, this blank could become a pivotal issue during a malpractice suit.
“It’s always better to put ‘N/A.’ If the record has to be defended, the physician can speak to the reason there was no need to do the exam,” says Karyn Finneron, RN, BSN, MA, HNB-BC, senior risk management representative for Boston-based Coverys, a provider of medical professional liability insurance. “Otherwise, it leaves physicians wide open for people to suspect they didn’t take the time to address it.”
With the section left blank, a plaintiff attorney typically would ask the physician a question such as, “Doctor, isn’t it true that you didn’t see the need to address the upper respiratory system because you were in a hurry that day?”
Physicians should consider their charting as part of the continuum of care, says Finneron. She suggest you ask this question, “If I am the next provider picking up the record, and I know nothing about this patient, is this going to be helpful to me going forward?” Finneron suggests these practices to reduce legal risks with EMRs:
• Indicate that specific examinations were done by another provider.
A woman might have had breast and pelvic examinations done by a gynecologist during her annual exam, for example. Primary care providers should ask for the date of these examinations and document the patient’s response. “This gives the rationale for the provider not doing the exam, because it was done by another provider,” she says.
• Specify that inaccurate information was corrected.
In one case, a patient’s allergy to Dilantin was mistakenly entered as Dilaudid, due to the information being entered from an illegible handwritten form completed by the patient. “It was not picked up until they had an external review. It never became a claim, because fortunately it was picked up before the patient was prescribed either drug,” Finneron says. This kind of correction should be specifically explained in the comment section of the EMR, she advises.
• Be sure a system is in place to alert you if patients fail to obtain diagnostic tests.
In one case, a patient diagnosed with bronchitis never went to receive the chest-X-ray the physician ordered, but the ordering physician didn’t realize that it was never obtained.
“The patient was just given a requisition to go for the X-ray. No system was in place to say that several days had elapsed, and the X-ray report wasn’t back,’” Finneron says. “The only way that the physician was put on notice for this was because the patient showed up in the ED and ended up being admitted for pneumonia.”
• Identify the alerts that are most meaningful to you, which will depend on the needs of the patient and the clinical specialty.
While physicians should be alerted if a patient fails to show up for a diagnostic mammogram, they might not wish to be alerted to a patient’s need for a routine mammogram.
“Physicians are turning off alerts because they are getting too many of them. If the plaintiff attorney can validate that alerts were ignored, that would not bode well for the physician,” Finneron says.
Source
For more information on liability risks of electronic medical records, contact:
- Karyn Finneron, RN, BSN, MA, HNB-BC, Senior Risk Management Representative, Coverys, Boston. Phone: (617) 526-0371. Email: [email protected].
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