As with anything electronic, medical record keeping is often flawed leading to malpractice lawsuits filed by patients and their families. According to Healthcare IT News, Electronic Medical Records also referred to as EMRs are at the heart of many legal grievances, costing medical facilities millions of dollars in payouts. Unsuccessful record keeping makes it possible for one physician to miss what another physician ordered for a patient.
The ‘Cut-and-Paste’ Phenomenon Costs Money
At HIMSS15, Keith Klein, MD, a clinical professor of medicine at UCLA, brought up one case where a simple urinalysis was missed due to poor electronic medical record keeping which ultimately led to advanced kidney damage in the patient. One witness explained that the EMR could be filtered to create flow charts and graphs much to the surprise of the judge who ruled in favor of the patient. This type of ‘cut-and-paste’ record keeping is inaccurate and highly criticized.
Ways to Fix Medical Record Flub-Ups
Klein suggested many ways to remedy the problems with EMRs. Among them included getting electronic signatures for informed consent meaning that a patient had to review and agree to what was electronically written in his or her chart. Other options include seldom using auto-complete, exercising caution when using templates, not overextending note sections where entire words and phrases are left off, and using a cut-and-paste option sparingly.
Advantages of Properly Using Electronic Medical Records
Proper documentation requires diligence. It also depends largely on education and familiarity with the systems being used. The advantages of utilizing electronic medical records properly are well-documented. In fact, when used properly, they save time, money, and space.
Some other pros of EMRs include:
- Increased number of patients served in a day’s time due to increased productivity.
- Ability to transfer data from one department to another for patients.
- Lower transcription and labor costs.
- Ability to e-Prescribe medication.
- Clinical documentation is advanced.
- Easier process to accurately process patient billing.
The intention behind EMRs is good. The execution, however, leaves a lot to be desired. That’s why electronic record keeping has gotten the bad rap that it has. With more and more medical professionals making medical errors when electronically documenting patient charts, it’s hard to see why the process is advantageous.
Doctor Criticize the Inefficiency of EMRs
Early critics of EMRs stated that typing information into a computer or tablet interfered with their ability to provide excellent care to their patients. Doctors and organizations called for more efficient ways to document common colds and sinus infections. Instead, they’ve been asked to click through dozens of screens to enter the information needing to be documented.
It’s easy to presume that speeding through pre-generated forms and drop down menus for the sake of saving time is what could very well lead to a medical error. As stated before, rambling notations and empty fields were cited as causes in flawed EMR keeping. Trying to make up for lost time by speeding through medical charts is something that causes concern especially where malpractice lawsuits are concerned because the medical documents serve as evidence as to what was and wasn’t included in a patient’s medical record.