Some prominent points:
- Lawyers are attending conferences on how to attack the electronic medical record
- Losing lab and x-ray data through failures in tracking
- Cut and paste was called "plagiarism" by the judge
- Using auto-complete without confirming the information
- Avoiding complex notes that are incoherent
- Understanding the limitations of electronic signatures
- Being careful with templates
- Lack of individualized information about the particular patient
- Gender confusion
- Positive findings in 1 section noted negative in another section
- Alert fatigue mistakes
- Typos and large number of empty spaces
The provider must never forget that the computer automatically captures the timeline of documentation in the document. However, that recorded timeline may not accurately represent the sequence of care. It is thus important to state the actual timeline (sequence, preferably with times) of clinical events in the clinical course of the medical decision making. Many cases that go to trial hinge on a comparison of times between the records made by the physician, the nurses, the other staff, and yes, now, the computer.
Read the final output before signing. A few words or sentences typed or dictated through voice-activated technology (e.g. Dragon) can insert meaning and coherence into an automatically synthesized notation that otherwise would read like "electric babble". Read the nursing notes. Explain any discrepancies. Read that last sentence again.
Acknowledge warning alerts and state in the record your medically appropriate decision, along with a brief summary of the basis for that decision.
The cost and complications of the electronic health record will continue to rise until the process is simplified and designed for end-users. It is going to get worse, before it gets better.