Navigating Electronic Health Records: Detailed EHRs Win Malpractice Cases

October 03, 2015

In an OncLive article published on August 6, 2015, Andrew Smith provides good advice on usingEHRs wisely to create accurate, useful medical records. Complete and easy-to-understand, EHRs can be essential in any future malpractice case. The article warns that if you are lax with recordkeeping, your EHR won’t serve you well when you really need it. Later on, you may need to rely upon the EHRs and EMRs (electronic medical records) you create today.

Accurate and complete health records are important every day, of course, to ensure proper patient treatment. The OncLive article points out that if you create good records, they will also help refresh your recollection in case you need to defend your actions later. Chances are, you won’t recall (without referring to your old medical records) the minute details required to defend yourself, since lawsuits are typically filed and adjudicated years after the medical procedure in question.

Getting Past the Growing Pains of Digital Health Records

EHRs are going through some growing pains these days. We haven’t yet arrived at a universal (or even dominant) set of best practices for information gathering, recording and sharing personal medical information—nor do we have software that communicates well between different computer networks. This gives digital health recordkeeping a big learning curve each time a medical professional moves from one medical office or hospital department to another. Realistically, these learning curves may not be completely mastered by busy clinicians focused on treating patients.

Despite the challenges, clinicians should concentrate on creating the most complete and accurate electronic medical record possible. In fact, you could do the entire profession a favor by consulting with software designers if the opportunity presents itself. A recent study by researchers at the National Center for Human Factors in Healthcare in Washington DC, published in the JAMAon September 8, 2015, found that EHR software is typically created without adequate clinical testing. So if you’re wondering how the not-so-useful online forms, illogically laid out computer interfaces and digital medical record apps were created, it may have been done without a doctor’s input — and the lack of understanding shows, as Scientific American points out.

How to Keep Effective EHR

To secure your patient’s healthy future and yours, don’t get too busy to keep accurate, detailed records. If possible, get in-depth training from the software maker. Don’t rely completely upon drop down menus or radio buttons. They don’t allow you to tell the complete treatment story or record the reasoning behind your treatment decisions. (And if you’re on a system new to you, you may not be familiar with how to use the form fields properly.) To ensure complete records, treating clinicians should always add detailed notes that can be understood later, by the next doctor or nurse — or by you years later if you need to refer back.

Remember, for the best EHRs, you should editorialize. Write/type (in nearby, handy text fields if possible) your findings, diagnoses, professional observations, dosage decisions and more. Your efforts will help ensure quality care and good continuity for the patient while providing you with detailed background information that may be vital years from now.

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Scientific American: