Liability and the Electronic Health Record

The electronic health record (EHR) should lead to patient safety and help minimize liability, but there are built in-traps that come with it. These traps can be subtle and can lead to quality reviews and potential liability for the provider.

Potential Traps:

1.      Timestamps—all over the place. These can be recorded but may not necessarily reflect true clinical activities. Not paying attention to document when things really happened.

a.      EKG was signed off 1 hour after the patient was already in the cath lab

b.      Clinical course out of sequence with CPOE and nursing notes

c.       When a consultant was called  and their advice

2.      “cut and paste”---“cut and paste”  Copying and pasting information can be as harmful as it is helpful. Information can easily be repeated or copied into the wrong section.

3.      “Cookie-cutter” charts that are  loaded with data that may or 

      may not have occurred.

4.      Inability to easily access nursing notes- and the converse. The world famous “DR aware” note.

5.      Not knowing the status of treatments orders, even though the computer says they are signed off.

6.      Clerical errors on the CPOE.

7.      Not creating a work-flow that emphasizes timed data points that affects LOS/time to provider/time to decisions. If the providers are not “clicking” the tracking board, the     data suggests inefficiencies. Hospital management only looks at the data and rarely any excuses.

8.      Timelines are much easier for the plaintiff's attorney to create, which may look jumbled even though the reality was different.

9.      Not checking the output on key areas to make sure it reflects what was supposed to be communicated.

10.  Receiving a transfer patient with “40” pages of computerized documentation and missing the key.

Dictation Software - The Best Way to Avoid Traps:

In the clinical course, use dictation software or voice-activated technology to create a recap of all the events. I prefer to use Dragon Medical dictation software. A quick summary will indicate the battle plan, the response, and the disposition.

Paper, dictated, and electronic charts are all good for the initial evaluation and the disposition, but the clinical course is usually murky and left up to the imagination.