How EHR Documentation Can Become a Liability

Paying close attention and not taking shortcuts during documentation can avert common mistakes, which are often costly for physicians.

Take this hypothetical situation for example, a patient goes into a surgeon’s office and, as is common with any medical visit, relays their allergies to medications. The patient states they are allergic to opioids and that the reaction is chest pain and itching. The patient also has another, rarer, allergy to cortisone, with a severe reaction of joint swelling, hives, endocrine issues and skin bleaching. Fast-forward a couple of weeks to surgery. The EHR that the information was entered into is part of a health system, so the information is available to be pulled up by the surgical team.

The procedure commences and opioids are given, along with a pain pump, which is common after this particular type of surgery. The patient goes into respiratory distress and nearly dies. In this scenario, ironically, it was not the medical team that discovered the error in the chart, it was the patient when they went into their medical records with their own password. Instead of seeing the reactions that were provided to the intake person at the physician’s office, the patient sees the following:

Allergies – codeine/opioids – reaction is mild diarrhea; cortisone – reaction is mild itching.

How did what the patient relayed to the member of the physician’s care team get so blatantly messed up? Using an EHR, there are three possibilities:

•The information was typed in wrong.

•The exact reaction was not available from the drop down menu and the staffer either did not know or was too lazy to use "other" and make an additional note.

•The staffer simply "cut and pasted" the information from the previous patient.

Needless to say, this scenario was completely avoidable. Here are some corrective measures that providers can take, to avoid these types of mistakes and the liability that comes from them:

•Adequately train staff, which includes telling them about law suits.

•Activate access controls and other mechanisms within the EHR, which prohibit the use of certain functions.

•Never copy and paste from one chart to another.

Accuracy in every aspect of patient chart documentation can lead to better outcomes and mitigate liability.  If all staff are not properly trained on documenting using a certain method such as EHR, the room for errors, and lawsuits, is increased.