Electronic Record Documentation “Fraught with Peril” If Users Unaware of Risks
November 14, 2014 | Strategic Insights for Ambulatory Care
Documentation in the electronic medical record (EMR) can be "fraught with peril" if users are unaware of the risks created by the electronic systems, said Craig B. Merkle, an attorney with Goodell, DeVries, Leech, and Dunn (Baltimore, Maryland), speaking October 27, 2014, at the annual conference of the American Society for Healthcare Risk Management in Anaheim, California. While features such as templates and drop-down menus are intended to save users time in documenting, they "can give me heartburn" in defending a case if the users do not consider the patient's individual circumstances, Merkle said. He gave an example of a template that was used for several days in a row to describe one patient's condition, although the template was designed for a different type of patient. "You lose all credibility in front of a jury," he said, if that record is needed for a litigated case. As another example, he described a drop-down menu selection that a provider used to describe a patient's condition because it was "the closest" in describing the patient's symptoms, even though the description was inaccurate.