EHR Documentation Presents Challenges for Defense Attorneys in Pressure Injury Trials

September 21, 2018 | Aging Services Risk, Quality, & Safety Guidance

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Healthcare professionals' use of the electronic health record (EHR) can present unique challenges for defense attorneys in cases involving healthcare organizations, said attorney Claire Neiger, Esq., with the law firm Goldberg, Miller & Rubin, at the fall conference of the Pennsylvania Association for Health Care Risk Management in Hershey (September 15, 2018). The EHR "can be difficult in the courtroom," said Neiger. For example, she noted the challenges of defending cases involving EHR templates that only allow for checkboxes, provide predefined answers, or provide limited space for narrative descriptions. The provider "needs space to write important notes," Neiger said. If, for example, the patient is undergoing diagnostic imaging when the system prompts staff to reposition the patient, staff should be able to document why they did not reposition the patient at that time.

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