Paper-based habits risky with EMRs Physicians should change charting practices
Charting practices used with paper records are not acceptable with electronic medical records (EMRs), warns Sandeep Mangalmurti, MD, JD, lecturer in law and fellow in the University of Chicago’s Section of Cardiology.
For example, some physicians fill out certain parts of the patient record before they actually occur for the sake of efficiency, such as completing an examination before it’s actually performed.
"If there is a bad outcome, everyone is going to know you filled the information out before you saw the patient," he says. "That doesn’t look very good." Mangalmurti recommends these practices:
• Explain any deviation from a clinical pathway included in EMR clinical decision systems.
The problem with EMRs that go beyond electronic ordering of medications or lab tests, and actually help guide clinical decision making, "is that to some extent, the EMRs are trying to substitute for medical judgment," says Mangalmurti. "This can be helpful to clinicians, but may also increase liability risks."
Deviation from these pathways, even if justified, can create an impression that the physician deviated from the standard of care. "Take the extra step to explain why you deviated from a pathway," says Mangalmurti.
• When transitioning to EHRs, move to a truly electronic system that is as complete as possible.
Physicians face increased legal risks when using hybrid systems that are half-paper and half-electronic, according to Mangalmurti.
"Physicians may have illusions that data is being electronically backed up, or that the record is more complete than it actually is," he explains. "There may be data that’s falling through the cracks electronically."