Electronic health records (EHRs) make information related to patient-centered records available instantly and securely, containing patient medical history, diagnoses, medications, and treatment plans that greatly assist with overall diagnosis and treatment. However, missing, incomplete, or ineligible documents may hurt patient care and be used as evidence if a patient claims negligent treatment. In order to best protect yourself, here is advice on how to ensure properly maintained EHRs:
Understand How the Data is Tracked
Each time someone at the practice or hospital goes into a patient record, data tracks who signed into the EHR, the physical location of the computer, and the exact update made to the EHR. This means that any possible delay in patient treatment that a physician seeks to rectify by having the EHR reflect assistance in a timelier manner can be pulled in the digital “audit trail” to demonstrate patient record manipulation.
What Should Be Documented
EHRs should be kept up-to-date to ensure you can demonstrate appropriate, timely patient care was provided. Since the EHR is used as a communication tool amongst all practitioners involved in the patient’s care, you want to document patient medical records in the manner that you would want documented if assuming management of the care of a patient you did not know. Do not forget to include a diagnostic rationale, especially in circumstances where the medical record could suggest another course of action that was overlooked.
You should also include details surrounding discussions with the patient, such as risks, benefits, and alternatives for certain courses of treatment, discharge instructions, follow-up plans, and correspondence related to the patient’s request or your decision to terminate the relationship.
What Should Not Be Documented
You should never include any derogatory or discriminatory remarks about the patient in the EHR. Any arguments or conflicts you may have with other physicians or nursing staff regarding treatment must also go through the appropriate chain of command, not the patient’s medical record. Avoid the use of subjective statements regarding prior treatment a patient may have received, and if an adverse event occurs between you and the patient, refrain from writing self-serving statements.
Do Not Alter Existing Documentation If a Claim Emerges
Any change made in the medical record is immediately obvious. Because of this, you can guarantee a plaintiff’s attorney will compare any medical record you provide to the copy of records the attorney has likely already attained. Even the slightest record alterations harm your credibility.
An accurate, detailed, and well-maintained medical record not only improves patient care, but also ensures you have clear evidence of the treatment provided to a patient throughout the course of their treatment. Problems can still arise even if taking the utmost care to ensure EHR maintenance, which could lead to you having to defend your license in front of the Illinois Department of Financial and Professional Regulation. If this occurs, Williams & Nickl can help you through the process and assist you in getting back on track. Our firm focuses on professional license defense of doctors, physicians, and nurses.