How Reliable are your EHR Patient Notes?

A disturbing number of EHR issues and medical professional liability claims are based on serious problems with exam notes and other clinical documentation recorded in an EHR.  Regardless of the legitimacy of care and treatment, the inappropriate use of EHRs and/or EHR design vulnerabilities are exposing physicians to questions on the quality of care and physician due diligence.  Some key areas to consider follow:

Initial Patient Charting:  In some cases, the transition of the patient information to the EHR was not adequately structured: resulting in serious omissions in the patient EHR based record.  For example, few physicians consider the patient care information and history that is needed to provide proper context in the EHR for a patient.  Previous surgical history and access to previous test results may be critical information to support continuity of care.  However, if the historical information is not properly entered, then the EHR will not provide appropriate warnings and notifications to the staff and physician.

Signing Notes:  If the EHR note is not signed, then the note remains open until someone signs it, or the EHR automatically closes the note.  Failing to sign a  note can raise a wide range of questions about the justification of billing and whether the doctor properly authorized care.  Any practice using an EHR should have an end of day process that includes verifying signing of all patient notes.

Systemic EHR Issues: Reliability issues may result in systemic problems for many or even all patient records.  For example, a note template may make representations that are not appropriate for all patients.  Similarly, a script that produces an exam form or a disability statement may have an error that appears on all documents issued by the practice.  The failure of the physician to understand how to accurately chart and verify patient information could lead to a wide range of care and compliance problems.  Avoiding systemic problems requires diligent evaluation of the clinical templates that you use, as well as periodic review of the EHR tools and their use.  In too many cases, practices treat EHRs as static tools, when in fact EHRs can change due to vendor upgrades and even daily use by physicians.

Amending Patient Notes:  Unfortunately, many EHR products do not provide all of the tools needed to maintain proper patient information.  Indeed, some EHR systems allow the user to attach a free text note to amend completed documentation, while the specific information in the note stays the same.  For example, you may enter free form text noting a change in findings, but the actual exam note still shows the original finding.  All EHR processes that use specific information to display an alert for a patient will be based on the original finding, and not the free form text addendum used to refine the note.  Thereby, the EHR could fail to warn you about a treatment standard, drug interaction, or emergent problem.

EHRs can be very useful and support outstanding patient services and effective clinical operations.  However, practices need to closely examine how the EHR is set up and used on a continual basis to maintain the efficacy of the patient records and efficiency of the practice. 



For more posts on EHRs and Medical Professional Liability Risks, click here.

To measure and address liability risks associated with how you use and maintain your EHR based patient records, contact Sterling Solutions at (800)967-3028 or click here.