A patient’s medical record is not only a living, breathing document of a patient’s health & care but it’s also a legal document that is usually the best defence against malpractice claims. Proper documentation is what will be used to prove whether the correct care was provided.

Malpractice claims have risen dramatically over the last decade. Doctors & providers simply have to be covered, both in terms of insurance & documentation, to protect themselves from such claims. It’s much easier to prove negligence on the part of the doctor if the attorneys present poor documentation, or worse yet, don’t have the documents to submit due to loss or theft.

Best Practices to minimise your risk

Your trail of patient care – be it paper-based or electronic – is how you potentially prevent medical errors, adverse patient outcomes & medical liability. Whether paper or electronic, common-sense best practices are still applicable & should include:

• Ensuring that the documentation is accurate, complete, relevant, & up-to-date.
• Avoiding cut-&-paste practices that can lead to mixed or contradictory messaging.
• Avoiding unsolicited comments
• Using standardised formats
• Reading the information once it has been entered into the system to ensure its correct before finalising a chart entry
• Any alteration to the record needs to be documented, timestamped & signed
• Attached documents such as diagrams, laboratory results, photographs, charts, etc. should always be labelled
• Continuing to educate yourself on how to improve record keeping.

How Electronic Medical Records (EMRs) help to further minimise your risk*

An Electronic Health Record is an electronic equivalent of your paper patient file. Good EMRs have built-in functionality that can work in your defence should you be presented with a malpractice claim. Here is how an EMR can minimise your risk:

• Timestamps: All data inputted into an EMR is timestamped & dated, minimising confusion about when something was done.
• Records deletion: Any notes deleted from a patient’s file need to be acknowledged. An EMR will hide notes with the reason for removal from the patient timeline, but will not delete the notes from the patient file.
• Standardised formats: When documenting patient information, it is important to do so in a standard format. EMRs standardise & organise data for you.
• Records patient communications: Should patients dispute being properly informed or not giving consent, using an EMR will enable you to send confirmation electronic communications that are linked to the file & can be used to help prove otherwise.
• Access tracking: Should a patient be concerned that their information was accessed by unauthorised users, an EMR can provide an accurate trail of who accessed the file & when.

Ultimately, whether done electronically or on paper, every medical provider should ask whether their charting can properly, completely & effectively communicate to all others who may need to review the information. Ensuring that effective & proper documentation is the standard, will have a positive impact on patient care & will keep doctors where they are needed – with their patients & not in the courtroom.

EMRs make proper patient charting easier. To find out more about the benefits of an EMR, click here.

*Not all technology is created equally, the benefits & functionality described in this article is based on Healthbridge’s Healthbridge Clinical.

Disclaimer: The information provided is general in nature & should not be considered sound advice. In all cases, you should consult with professional advisors familiar with your particular situation before making business, legal or any other decisions.

You might also be interested: Holiday checklist: Essential medical items to pack