Understand the issues and charting errors that may arise with electronic medical records and how to prevent inaccurate records.
With the adoption of electronic medical records, decades worth of documentation and best retention practices based on maintenance of a paper records has been rendered moot. For all the time, money and effort, EMR systems were not prepared or designed for production to other providers or third party request for records. Charting and production errors can have a widespread negative impact on patient care and can be easily discovered in a subsequent medical negligence lawsuit. This topic on preventing inaccurate medical records will help all involved in health care information to minimize exposure to claims and improve patient care. The content will identify the top issues faced by practitioners if they are sued for negligence or have their treatment of a patient called into question. Failing to know your charting problems ahead of time only hampers investigations and limits accurate evaluations of health care. This educational topic should be a must for all who distribute, review and request health records including health information specialists, risk managers, claims consultants and medical malpractice attorneys. Otherwise, they may not even know when they are dealing with an incorrect record that may be detrimental to the care of patients.
Common Charting Errors
ï Garbage in, Garbage out - the Importance of EMR Training
ï Legibility and Documentation Standards
ï The Truth of Documentation - How Timing Impacts an Entry
What a Production?-How You Provide Information Is Just as Important as How You Document Information
ï Paper Records vs. Hard Copy Printouts of EMR
ï Common Production Issues
ï The Importance of Embedded Information and Why It Is Coveted
Isn't Technology Great?-New Issues Regarding the Medical Record
ï Sharing of Information Between Systems in a Health Network
ï Problems With Multiple Access Points
ï Other Devices That Memorialize Record Outside of Official Record
Matthew P. Keris, Esq. with Marshall, Dennehey, Warner, Coleman & Goggin
ACHE ,AHIMA ,HFMA ,Additional credit may be available upon request.