Four things to watch for when reviewing electronic medical records

In the past decade, health providers have made big changes in the way they document patient visits, monitor lab results and track their patients’ health.

Gone are the paper forms. Here to stay are the tablets and software programs where nurses and doctors record their patients’ health information. Adoption of these Electronic Health Records was among the key pieces of the Health Information Technology for Economic and Clinical Health Act of 2009 and the Federal Health IT Strategic Plan.

So far, the federal government’s efforts to encourage the move to these electronic records has paid off. According to a May 2016 report, by 2015, more than 4 in 5 of all non-federal acute care hospitals had adopted a Basic EHR with clinician notes. About 80 percent of small hospitals with less than 100 beds, rural hospitals and critical access hospitals had done the same.

When used correctly, Electronic Health Records can come with plenty of benefits, including better follow-up of test results; improved care coordination; cost savings and efficiencies; and increased patient participation. But, just because health care facilities have implemented this electronic recordkeeping, it doesn’t mean every doctor fully uses them.

According to a data analysis published in the June issue of Applied Clinical Informatics, researchers found that 43 percent of primary care physicians used workarounds – typically pen and paper. Doctors preferred alternative methods for three reasons: as a memory aid, for improved efficiency and for easier internal and external care coordination. Researchers concluded that future EHRs and work systems need to evolve to meet providers’ needs.

If you’re reviewing Electronic Health Records for a case or a claim, here are four things to know:

Not necessarily easier: It might seem counterintuitive, but electronic records often are much more difficult to cross reference than a traditional record. If the software for a hospital and a clinic, for instance, can’t communicate with each other and access the other’s electronic records, it makes it more difficult to track every record and result.

Not necessarily better: Each hospital has its own Electronic Health Record system and none of them necessarily improve patient care or documentation. Some are pieced together. Some components, even within a single health system, can’t communicate with each other. So always determine if there still might be a paper trail.

Audit trail opportunities: Electronic Health Records do give us important access into the history of a case. The date and time stamps are vital pieces of information for determining whether records were tampered with. Always complete a chronology of any record – written or electronic – so that inconsistencies, gaps and possible tampering are clearly identified.

Shortcuts everywhere: Electronic Health Records require doctors to key in more information compared to paper methods. To save time, providers often simply copy and paste as they move forward through the record, which is sloppy and often leads to inaccuracies. In many cases, standardized templates aren’t appropriate for a particular case. Workarounds are everywhere. These non-standard practices can make for inadequate documentation, poor patient outcomes and potential lawsuits.

When reviewing any kind of record – written or electronic – it’s important to review them with a critical eye and ensure you’re looking at the full picture.

Need help? MKC Medical Management’s highly trained Legal Nurse Consultants review medical records with the knowledge and experience to tease out the most vital information and get it right the first time.