Clinical content refers to the various checklists, documents, and forms that address an area of medicine when using an EHR. For example, a pediatric practice would be interested in documentation tools for a newborn visit. Not all EHRs have clinical content for all areas of medicine. For example, some EHRs have clinical content for internal medicine, but lack the details needed for dermatology or cardiology.
A disturbing number of practices have failed to analyze the clinical content of their EHR and are distributing exam documents and other information that do not adequately or accurately document patient care. In the more serious situations, EHR clinical documents misrepresent the care provided and the patient’s condition. For example, one practice was distributing exam notes that had inappropriate gender information for all patients. In another situation, a specialist included extensive ROS information on the patient’s cardiovascular system which was not performed and not the specialist’s area of expertise. Such problems could precipitate a wide array of care, insurance, and medical professional liability issues.
