Attorneys involved in medical litigation may be increasingly receiving electronic medical records from hospitals for medical record review purpose. The entire medical chart or some parts of it may be computerized. Either way, there are certain challenges attorneys need to be cautious about when reviewing electronic medical records.
- The copy-paste problem: this is one of the worst nightmares in connection with electronic healthcare records. Physicians and nurses alike have a tendency to copy paste outdated information, without conducting proper assessment of the patient. This is common in instances when the nurses do not notice any significant changes in the patientâ€™s condition, and copy the documentation provided by the nurse in the previous shift.
- Confusing data in the records: notes that are repetitive and provided in different formats make it quite frustrating to understand a patientâ€™s actual condition at a particular time. In such cases, attorneys will have to peruse various sections of the medical chart to gather accurate information.
- Identifying lost data in summarized physiciansâ€™ orders: often attorneys are faced with the problem of missing data such as the physician who gave the order, the time the order was written and the nurse who transcribed the order. This is a common issue when pharmacy, lab or nursing departments summarize the orders.
- Understanding metadata: attorneys must have a clear understanding of the metadata which provides details such as the person who used a computer/application, and how and when it was used. The audit trail will provide details such as the person(s) who looked at the medical records, when and for how long the medical records (hard copy) left the medical record department, as well as the edits, additions and deletions for the particular time frame. It also provides details about the people who made these modifications.
- Understanding abbreviations and particular usages of the facility: this is important with regard to clearly comprehending the facts in the medical records.
- Ensuring that you receive the complete set of medical records pertinent to the case: you need to make sure that you get all relevant data, even those that may be contained in paper records.
- Ask for the PHI disclosure log: this is a list showing what patient data has been disclosed, where it has been disclosed, by whom and to whom it has been disclosed. You will need this to locate other copies of the medical records for comparison.