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If discharge documentation isnt complete and accurate, coders may not use the correct discharge status code, which could affect a hospitals reimbursement.
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Electronic medical records (EMRs) can potentially help to prevent missed diagnoses with “results management” systems that track outstanding clinician orders for diagnostic tests.
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News: The patient, a 40-year-old man, sought treatment in May 2008 for chronic lower back pain at a pain clinic operated by two physicians. The initial treatment, which consisted of medication injections into the patient’s back, was successful for a time, but the patient returned to the clinic three more times seeking further pain relief.
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The patient, a 37-year-old woman, was prescribed the oral contraceptive pill Yasmin by her physician in an attempt to control irregular bleeding. Thirteen days after she began taking the medication, she suffered a stroke that resulted in serious brain damage.
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Publically reported data on payments made to physicians will be available in September 2014, as a result of The Physician Payment Sunshine Act. This could help plaintiff attorneys to strengthen malpractice claims.
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Inaccurate electronic medical record (EMR) entries have complicated the defense of some malpractice cases.
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Time-stamped electronic medical record (EMR) entries can complicate the defense of a malpractice claim if they provide a reason to question the physician’s credibility.
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Some electronic medical record features can result in physicians using “workarounds” to streamline documentation, but these actions can be legally risky. Plaintiff attorneys look for indications that physicians:
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Physicians are using electronic medical record (EMR) functions that result in authorship falsification, disabling of audit logs, and document misattribution without understanding the legal implications.
