Proper documentation is crucial when it comes to a patient's medical record, as it serves not only as a record of the patient's health and care but also as a legal document. In cases of malpractice claims, the medical record is often the best evidence to prove whether the appropriate care was provided. Therefore, accurate, complete, and up-to-date documentation is necessary to protect both patients and medical professionals.

In recent years, malpractice claims have been on the rise, and it's imperative for doctors and healthcare providers to take measures to protect themselves. Ensuring proper documentation and having adequate insurance coverage can minimize the risk of such claims. It's important to note that attorneys can easily prove negligence on the part of medical professionals if they present poor documentation or lack the necessary documents due to loss or theft. Therefore, it's essential to maintain a high standard of documentation to avoid any legal disputes.

Best Practices to Minimize Risk:

The documentation of patient care, whether in paper or electronic form, is a crucial factor in preventing medical errors, negative patient outcomes, and medical liability. Regardless of the format, the following common-sense best practices should be applied:

• Ensure documentation is accurate, complete, relevant, and up-to-date
• Refrain from using cut-and-paste techniques that can lead to contradictory messaging
• Avoid uninvited comments
• Use standardized formats
• Read information once it has been entered into the system to ensure correctness before finalizing a chart entry
• Document any alteration to the record, timestamp it, and sign it
• Label attached documents such as diagrams, laboratory results, photographs, charts, etc.
• Continuously educate yourself on how to improve record keeping.

More ways to Minimize risk with Electronic Medical Records (EMRs)

An EMR (Electronical Medical Health Record) is essentially an electronic version of a patient's paper-based medical record. Good EMRs have built-in features that can provide defense in case of malpractice claims. Here are some ways in which EMRs can help minimize your risk:

• Timestamps: In EMR, every piece of information entered is marked with a timestamp and date, which helps prevent any confusion regarding the timing of events.
• Deletion of records: 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.
• Consistent formats: It's crucial to use the same format when recording patient information. Electronic medical records (EMRs) help standardize and arrange data automatically.
• Records communication from patient: :EMRs can provide a way to send electronic confirmations that are linked to a patient's file, which can be useful in situations where a patient disputes being informed or giving consent.
• Tracking of access: If a patient is worried that someone who is not authorized saw their information, an EMR can show them exactly who accessed their file and when. This means they can keep track of who has seen their information.

Medical providers should ask themselves if their charting can effectively communicate to everyone who needs to review the information, regardless of whether it's done electronically or on paper. Having proper documentation standards can improve patient care and prevent doctors from spending unnecessary time in court.

It is important to note that not all technology is created equally. The benefits and features discussed in this article are specific to Healthbridge's Healthbridge Clinical.

Disclaimer: The information provided in this article is for general informational purposes only and should not be considered as professional or sound advice. We recommend consulting with professional advisors who are familiar with your specific situation before making any business, legal, or other decisions.