- The healthcare provider is legally responsible for the medical record not the vendor and/or consultant even if there is the claim of a faulty product..
- Copy and pasting text.
- Lack of password control. Sharing your password may allow certain entries and/or additions to look like provider direct input.
- Ignoring clinical decision support without careful documentation of why.
- Customizing your electronic health record without realizing you may be affecting the main data base. Critical pieces of data must be acknowledged not just placed in the body of the note.
- Using the meaningful use criteria for payments may lead to a change in the standard of care.
- Entering incorrect information due to time pressures.
- Altering the patient-provider interaction by focusing on the computer screen, not the patient.
It is advisable any provider should read the entire article. Most of the time, worry about these points is unnecessary. However, the majority of lawsuits and complaints cannot be predicted in advance. The best solution is to fully understand that every feature an electronic health record offers has some potential downside. If aware, the provider can compensate with some explanation placed directly in the record.
The legal field is getting more sophisticated about its analysis of the electronic health record and using it to their client's advantage. One of the huge issues is the creation of complex meandering timeline of events. The computer documents the exact time the data was input, but does not realize when the actual events occurred. Spending a little time on the clinical course can put large amounts of data in a logical order.