Concerning Best Practices for Entering Data into a Patients Electronic Medical Record
In this episode, Healthcare Matters interviews ALL MD attorney John Degnan on how the move from paper to electronic medical records has altered best practices for entering patient data into his or her chart.
Degnan is a shareholder at BRIGGS & MORGAN. He practices law in Minnesota, representing clients in business disputes, as well as members of the legal and medical communities in professional matters.
Degnan is a charter member of the Association of Liability Lawyers in Medical Defense (ALL MD), a nationwide organization that connects healthcare providers with attorneys who specialize in medical malpractice defense.
Question 1 of 5
Interview was recorded September 4, 2015
Mike Matray: Hi, and welcome to Healthcare Matters where the medical and legal communities come together to discuss healthcare matters. Today’s guest is John Degnan.
Welcome to Healthcare Matters, John.
John Degnan: Thank you. I’m happy to be here.
Mike: How has the move from paper medical records to electronic medical records affected best practices for entering data into a patient’s chart? And what guidance would you give physicians so that they’re using best practices when entering data into their patient’s medical records?
John: Well, overall I think it’s a very positive move because it leads to a lot more continuity even across different medical providers. However, there are some adjustments that, I think, have to be made by physicians. For example, the most important thing is to make sure that the dropdowns or checklists that are used are absolutely accurate for that individual patient. Close doesn’t count, obviously, in charting. And so if indeed some of the dropdowns don’t exactly capture what the situation is for that physician, it’s very important to be able to free-text or explain it so that at the time it’s accurately recorded so that later on it will help. Not only in the care for patients but in the event of any claim or question about the care.
The other is to be careful about corrections being made. It should be done like it used to be. That is making it clear that there are tracks in the snow because some providers that allow for deletions but some of them later on show up only as deletions and don’t show what’s deleted. So it looks like some record is destroyed. So it’s very important to leave what I call the tracks in the snow.
Mike: So even a benign deletion could be considered to be nefarious?
John: Absolutely. We had one case in which it was good care, defensible case. But there were about 10 items where there were deletions of just simple words. But the way that that provider had it set up, all it showed was deletion, and so it looked like destroyed evidence. There was an adverse inference called for. In other words, it must have been bad, ladies and gentlemen of the jury, or they wouldn’t have destroyed it. It led to a case that should have been defended but couldn’t be. And the cost for it was about two to three times what the value was just because of the prejudicial nature of that.