By: ProAssurance

Electronic Medical Record Systems (EMRs) streamline, modernize and, in many ways, improve medical record documentation.

From a practical standpoint, the way medical information is entered and stored in an EMR system is vastly different from a traditional paper chart. Conceptually speaking, however, EMRs are no different from traditional, paper-based medical records. They should still reflect all clinically relevant aspects of the patient’s health care and serve as a vehicle for memorializing information about the patient’s health.

The medical information in an EMR must be legible, timely, accurate, chronological, thorough and objective. The record should describe the patient’s medical history, medical conditions, diagnoses, the care and treatment you provide and the results of such treatment. The same guidelines with respect to corrections, addendums, late notes and retention and destruction of paper charts also apply to EMRs. In short, all risk management guidelines that pertain to traditional medical records apply with equal force to EMRs.

As the use of EMRs becomes more widespread, new risk management issues have arisen. Several existing EMR risk management issues include:

• System security: Patient information must be protected from unauthorized access. Determine who will have access to your EMR system and to what extent. For example, will the level of access be driven by job function? Can physicians access the records off-site? In choosing and implementing an electronic system, consult information technology specialists and legal counsel to ensure that your EMR system security complies with all applicable state and federal laws.
• Pick lists and drop-down boxes: Pick lists and drop-down boxes are convenient, time-saving features of EMRs. They also create the temptation to cut corners with respect to complete and thorough medical record documentation. Ensure that your system has a “free text” area to accommodate a patient’s complaints, symptoms and any diagnoses that may not match choices available on pre-populated lists.
• Built-in tracking systems: Many EMR systems have built-in tracking systems for preventive health maintenance and routine reminders, as well as the capability to track the results of labs, X-rays, and other diagnostic tests. Avoid EMR systems that lack comprehensive, built-in tracking systems.
• Incoming test results: How are incoming test results viewed, reviewed and documented? Find a system that enables you to review and electronically “sign off” on test results.
• Corrections, addendums and late notes: A proper EMR system should permit you to make corrections, addendums and late notes to a patient’s medical record. The system should track the author, date and time of the addition and maintain the original entry.
• Readability of printed copy: Confirm that all staff members who may eventually need to interpret any part of the medical record are familiar with the printed format. A printout of a patient’s chart may look different from the electronic version. Does the hard copy tell a logical story about the patient’s health and related treatment? If not, find a system that does.
• Adequate training: It is imperative to adequately train staff in using the system to prevent disruptions in care caused by misunderstanding of the EMR system.

More educational resources for EMRs are available on the website of the Office of the National Coordinator for Health Information Technology. 

ISMA members insured by ProAssurance may contact the ProAssurance Risk Resource department for prompt answers to liability questions by calling 844-223-9648 or via e-mail at RiskAdvisor@ProAssurance.com.