Computerized Medical Documentation – Benefits and Challenges for Attorneys

by | Published on Sep 21, 2015 | Medical Record Review

The electronic medical record comes with many distinct advantages that cannot be offered by the paper medical chart. Primarily, the huge amount of patient data that is generated can be stored in a more organized and efficient way. Important pieces of information can be easily found, and considerable effort and time saved through the use of the EMR system. Authorized people in remote locations can access the records when required. Electronic health records ensure standardized documentation and reliable information.

Medical record review is an integral part of medical litigation and electronic healthcare records prove advantageous to attorneys as well.

  • Since no handwritten records are involved, the documentation will be perfectly legible. This will help to avoid confusion that may arise from illegible handwriting that is very much part of paper records.
  • Attorneys can easily identify the healthcare provider by means of the full name, or initials and status that follow each entry. Each entry carries a time stamp and date as well as the identity of the caregiver.
  • Important healthcare information will necessarily be entered by healthcare providers who are prompted by programs that incorporate the healthcare facility’s standards of care. the existence of such programs bring key clinical issues to the provider’s view so that he/she obtains and enters the data that would fulfill the standard of care, and help the defense attorney’s case.

In spite of the evident advantages, the electronic medical record is haunted by safety issues. Recent news mentioned an important study carried out by Microsoft researchers that found many databases used for EMRs are at risk of information leak even though encryption is used. Computerized documentation is somewhat stereotyped, and the same stock terminology may be used again and again as a result of which the medical charting of patients may sound alike. While provision for narrative notes entry may be there in most EHRs, providers sometimes do not take the time to enter those notes. This may in turn prove difficult for the attorney trying to build up a clear picture of the patient’s status. When narrative notes are not clear, it will be more challenging to analyze liability in medical malpractice cases.

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