The healthcare provider is legally responsible for the medical record not the vendor and or consultant even if there is the claim of a faulty product.
Copy and pasting text.
Lack of password control. Sharing your password may allow certain entries and/or additions to look like the provider’s direct input.
Ignoring clinical decision support without careful documentation why.
Customizing your Electronic Health Record without realizing you may be affecting the main data base. Critical pieces of data need to be clicked not just placed in the body of the note.
Using the meaningful use criteria for payments may lead to a change in the standard of care.
Entering incorrect information due to time pressures.
Altering the patient-provider interaction by focusing on the computer screen, not the patient.
It is advisable any provider should read the entire article. Most of the time, worry about these points is unnecessary. However, the majority of lawsuits and complaints cannot be predicted in advance. The best solution is to fully understand that every feature an Electronic Health Record offers has some potential downside. If aware, the provider can compensate with some explanation placed directly in the record.
The legal field is getting more sophisticated about its analysis of the Electronic Health Record and using it to their client’s advantage. One of the huge issues is the creation of complex meandering timeline of events. The computer documents the exact time the data was inputted but does not realize when the actual events occurred. Spending a little time on the clinical course can put large amounts of data in a logical timeline.
XpressTechnologies Electronic Health Record was created “For Doctors by Doctors” with all the malpractice concerns built in to protect the provider. Our chief complaint driven templates with imbedded risk factors, ability to document times when the event actually occurred, extensive clinical course and consultation boxes, ability to create personal text macros, and easy integration with voice activated technology makes for an ease to use, realistic medical record.