Earlier, one of the major concerns when providing medical record review services was the illegible handwriting of physicians. The electronic health record was introduced and made mandatory with a view to improve the quality of care, reduce medical record errors, and to cut healthcare costs. However, EHR systems have their own flaws that hinder smooth flow of the review process. At present, more than 83% of doctors use EHR systems in their offices, but the medical documentation seems to have increased. When doctors were writing their notes, documentation was crisp and to the point. EHRs require much more documentation before, during, and after a patient visit.
Increased Documentation to Review
Thus, when it comes to medical records review for a medical malpractice case for example, you will find voluminous notes with each note having a complete medical history, review of systems, and physical exam. To save time, many physicians tend to copy-paste information and this could make each note appear almost identical to other notes – only the dates will be different.
When a medical chart is reviewed, the focus points are whether the doctor:
- Made a correct diagnosis
- Obtained a reasonable history and physical
- Ordered relevant lab tests, imaging studies, EKG etc.
- Considered a reasonable differential diagnosis
- Prescribed appropriate treatments
The effort would be to find out whether any deficiency in the care provided led to the poor outcome or adverse event.
Medical Malpractice Concerns
Because of the increased documentation with the electronic health record, the patient chart review takes a longer time to complete. Besides that, reviewers often come across many discrepancies. For instance, there may be a new diagnosis mentioned without supporting physical exam description. Such irregularities or variations in documentation could compromise patient care. If the doctor fails to arrange for follow-up visits to examine the progress of the condition, the patient could even die, giving rise to medical malpractice lawsuits. The EHR calls for more close scrutiny of the medical record to identify inconsistencies. From a legal point of view, EHRs are often discoverable and may increase doctors’ liabilities.
One major grievance that doctors have is they have to spend more time on EHR documentation than on paper charts. Many of them try to enter the information during their consultation with the patient. This leads to poorly organized notes, and patient dissatisfaction when they find that the doctor is not focusing totally on them. Another significant thing to note is though EHR technology has features such as pop-up alerts, clinical decision support, clinical prediction rules, follow-up reminders and so on, they needn’t be based on relevant scientific evidence. The problem is that if the physician deviates from these “standards” they could be held liable.
Best Practices to Follow
Whether electronic or the traditional paper format, the medical record is often the most pertinent evidence or the documentary evidence that the legal system relies on in a case of medical negligence. Insurance companies also require proper medical record maintenance to prove the medical necessity of various treatments provided. Poor record keeping translates to poor defense for the doctor. Doctors should therefore focus on adopting certain best practices that will act as the best defense for them.
- Whatever be the treatment provided, the doctor has to obtain a properly written consent from the patient. This will help prove that the procedures were conducted with the consent of the patient.
- If a surgery is provided, a properly written operative note will defend the surgeon if there is alleged negligence due to operative complications.
- All drug prescriptions should be clear with the name of the patient, date, and the provider’s signature.
- Nursing care, lab data, diagnostic evaluation reports, pharmacy records, billing processes and so on must be properly recorded.
- All nursing staff as well as the paramedical team must be properly trained in medical record documentation and maintenance.
As a medical chart review company assisting medical malpractice attorneys, we understand the significance of good medical record keeping, both from the medical and the legal viewpoints. Providers need to be aware about the increased chance of conflicts with the introduction of electronic health records and patient portals that allow patients to access their own medical records.