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Chicago licensure attorneyElectronic 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.

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