Follow These Tips to Avoid EHR Documentation Errors during COVID-19

The COVID-19 has placed huge challenges, like those experienced never before, on healthcare providers and EHR (Electronic Health Record) systems have to adapt to the changing requirements for patient care. Though EHR systems have many benefits and have made processes such as medical claims review easier, it is not clear whether these systems can withstand the onslaught of the current global healthcare crisis and continue working efficiently. A major concern in the present context is accurate and timely electronic medical record documentation because of the overwhelming number of COVID-19 patients flocking to hospitals and other healthcare facilities. It is feared that there could be serious disruption to EHR documentation, and hurried, incomplete, and erroneous entries. To add to this, there could be EMR or EHR workarounds as well. Such concerns raise the issue of medical malpractice risk, when in the present context there could be increased inspection of the electronic health record and audit trail.

So, what’s the solution?

Healthcare providers need to maintain accuracy and efficiency in the medical charts of their patients. To avoid documentation issues related to the EHR in the COVID-19 context, there are certain important steps they can take.

• Extra caution in ensuring accurate and efficient documentation: Physicians and all other clinicians must be extra cautious when documenting everything related to patient care. Some U.S. states have issued executive orders that have lightened record keeping requirement for healthcare workers during this pandemic. The state of New York has relieved providers of record keeping requirements “to the extent necessary for healthcare providers to perform tasks as may be necessary to respond to the COVID-19 outbreak, including, but not limited to, requirements to maintain medical records that accurately reflect the evaluation and treatment of patients, or requirements to assign diagnostic codes or to create or maintain other records for billing purposes.” However, expert observers in the field say that even in the presence of such provisions, accurate and strong documentation is the best defense for healthcare providers. Clinicians are advised not to skip or rush through accurate documentation of all actions they have taken or recommended to patients. In connection with the pandemic, documentation is very important to protect doctors as well as patients, and for research purposes.
• Take care to avoid medical coding errors: The patient records should accurately reflect services provided.
• Do not alter the medical record: If any alteration needs to be made at a later stage, provide the reason for making the amendment.

Attorney Matthew P. Keris, in his post published in marshalldennehey.com, gives the following recommendations.

• Maintain up-to-date and accurate hospital staffing records: To fight the pandemic, hospitals may have increased their reliance on agency nurses, retired doctors and nurses, and other providers who may not be very familiar with the electronic medical record system. Such staffing records must be scrupulously maintained, and it would also include records related to staff reporting sick or staff call-offs. When such staffing records are maintained well, they would explain issues such as lack of or no information in a medical record and documentation errors. Moreover, information regarding such temporary staffing will be crucial when it comes to describing the care rendered during the period.
• Document any technical glitches experienced with the EHR: Technical issues could create problems with the EHR system, which a provider may be called upon to explain at a later time if there is a malpractice lawsuit.
• Get in written form that the documentation requirements have been relaxed during COVID-19: It is important to include the acknowledgment that patient care documentation should be performed “as soon as reasonably possible” as against “simultaneous to the care rendered,” because this will help avoid future arguments that a staff member violated hospital documentation protocols during the epidemic.
• Maintain accurate documentation regarding any duties/privileges that have been temporarily changed or expanded: Only this can ensure why a certain person documented a certain information.
• Examine all EHR workaround practices for safety purposes: It is vital to put an end to any risky practices identified. However, it is best to keep an open mind in the case of legitimate workarounds and eliminate unnecessary EMR redundancies to ensure improved care.
• Minimize provider “footprint” in the EHR after the patient is discharged from the hospital: Attorney or medical peer review involvement within the EMR may not be protected in states where the audit trail is held as an “original source” document just as the hospital chart. Before an attorney or peer review of the electronic medical record is conducted, it is important to consider whether such involvement will be produced later in the form of an audit trail. Since there is no clear guidance regarding this sensitive issue, to prevent the patients’ lawyers from understanding the potential weaknesses of a case via an audit trail, a review of a hard copy printout of the EMR may be the best option.

The above-mentioned documentation practices should help healthcare providers avoid EHR-related malpractice risk during this pandemic. Good documentation practices will enable medical information about patients to be readily available across the entire healthcare spectrum irrespective of the patient’s location. It will also facilitate medical record analysis that is necessary for ensuring better patient care, and also in connection with medical-legal litigation.