Unsure how EMR works? It’s legally risky
What you don’t know can harm defense
When saved medical record information is deleted, electronic medical records (EMRs) vary as to whether this information is stored. In the event of a malpractice suit, stored information could become very important.
"It is easier to defend an allegation of medical record alteration if every entry is stored," says Marlene Nazarey, RN, MSN, CPHRM, risk control director in the Healthcare Segment at CNA, a Chicago-based provider of professional liability insurance. For example, if a physician mistakenly documents a note intended for another patient’s record and then deletes the note and writes the correct note, there still should be evidence in the EMR of the original note and the correction made. "When purchasing an EMR, it is important to ask the vendor whether every entry is stored, even error corrections," she says. "In this way, the integrity of the medical record can be demonstrated. No alterations can be made without a record of the entry."
Here are important things for physicians to know regarding metadata:
• The time that the documentation entry is made is recorded in the medical record.
Information might have been obtained from the patient earlier, as when a doctor sees a patient before making the entry.
"Physicians should document as soon as possible after assessing or treating a patient," Nazarey advises. "If this is not possible, such as in an emergency situation, then document the time that the assessment or intervention occurred in the progress notes."
• Specific computer actions trigger data being saved.
In most systems, each subsequent change to the note is recorded to create a time-sequenced record of changes to the chart. "Once the physician has finished documenting a note, there is usually a submit button or other similar type button to click to indicate that the note should be saved," says Nazarey.
If physicians weren’t adequately trained on the EMR, they could inadvertently fail to save the note as intended. "Thorough training on the EMR is important for this reason," says Nazarey.
• Some data is saved, which is not included in a medical record printout.
"There may be data saved related to what screens were viewed by the provider and when," she says. "Such data creates a footprint’ of who viewed what part of the medical record and when."