A disturbing number of EHR issues and medical professional liability claims are based on serious problems with exam notes and other clinical documentation recorded in an EHR. Regardless of the legitimacy of care and treatment, the inappropriate use of EHRs and/or EHR design vulnerabilities are exposing physicians to questions on the quality of care and physician due diligence. Some key areas to consider follow:
Initial Patient Charting:
In some cases, the transition of the patient information to the EHR was not adequately structured: resulting in serious omissions in the patient EHR based record. For example, few physicians consider the patient care information and history that is needed to provide proper context in the EHR for a patient. Previous surgical history and access to previous test results may be critical information to support continuity of care. However, if the historical information is not properly entered, then the EHR will not provide appropriate warnings and notifications to the staff and physician.