Whether to understand the type of care provided to the patient, for medical record review, for obtaining billing information, or for information exchange, electronic health records or EHRs are much more efficient and convenient that traditional paper records. One of the important uses of the EHR is as a legal record. It contains detailed health information about the patients in digital format and are designed to share information with other healthcare providers/organizations such as laboratories, medical imaging facilities, emergency facilities and pharmacies among other entities. The EHR contains information from all clinicians involved in the care of a patient.
As mentioned before, the health record of a patient is an important legal as well as business record for the healthcare organization. The legal requirements for maintaining electronic health records are more complex than those for paper health records. If these are not maintained in a legally sound way, they could very well be challenged as invalid. The EHR must be properly designed and providers must be able to use it appropriately in strict adherence to federal and state rules, as well as institutional requirements and additional certification standards applicable to the healthcare organization.
The major purposes served by the medical chart or medical record of a patient are:
- Enables communication of healthcare data among the healthcare team members.
- It documents compliance with standards that need to be met for reimbursement by a third-party payer such as Medicare, Medicaid, or another insurance carrier.
- Documents compliance with standards of care and standards of various accrediting organizations and the state health department.
- Documents that the care provided to the patient meets safe, effective, and legal requirements.
What information does an electronic health record contain?
- Patient demographics
- Administrative and billing information
- Progress notes
- Vital signs
- Diagnoses
- Medications
- Immunization details
- Medical history
- Allergies
- Radiology images
- Lab and test results
The primary purpose of medical record documentation is to ensure superior quality patient care. However, when errors creep into the health record, it poses risk to the patient and also has legal implications. Issues in documentation can become really serious when there are allegations of malpractice, medical negligence, failure to meet standards of care, and so on. Proper and accurate documentation will reduce the risks of a lawsuit against the healthcare provider and the organization employing him or her.
The charting errors to avoid include the following:
- Not recording relevant health or medication information
- Failing to record nursing actions
- Recording in the wrong patient’s medical record
- Failing to record medication administration
- Not recording a medication that has been discontinued
- Failing to note down drug reactions or changes in the patient’s condition
- Failing to transcribe orders properly or transcribing improper orders
- Preparing incomplete or illegible medical records
Providers must necessarily avoid the above charting errors to prevent medical malpractice allegations and lawsuits. Mostly, discrepancies in the medical record create considerable challenges when defending a malpractice suit. Such inconsistencies usually involve physicians, nurses, advanced practice clinicians, EMS personnel and any records associated with the patient. The discrepancy may only be a minor difference in terminology used in the record but sometimes these discrepancies can be serious ones.
Typical examples of discrepancies in medical record documentation include:
- Details of injuries
- Medication lists
- Differences in describing pain and other complaints
- Neurological and abdominal exams
- Patient response to treatments
As a medical review services provider to medical malpractice and personal injury attorneys, we can say that accurate and concise medical record documentation is vital to provide patients with high-quality care, mitigate malpractice risks, and ensure timely and accurate payment for all healthcare services provided to the patient. Accurate medical records enable providers to evaluate, plan and provide proper treatment to the patient across the healthcare continuum.
