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SAN FRANCISCO (FRONTLINE MEDICAL NEWS) – Are electronic medical records wreaking havoc for you? Herschel R. Lessin, MD, vice president of the Children’s Medical Group in Poughkeepsie, N.Y., had some EMR recommendations.
In his presentation entitled “Help! My EMR Threw Me Under the Bus!” at the annual meeting of the American Academy of Pediatrics, Dr. Lessin offered the following recommendations for troubleshooting or preventing EMR problems, starting with customizing your EMR right away to reduce alert fatigue.
• Document the specifics of a particular condition, treatment, history, or other note when checking boxes.
• Document your thinking in terms of differential diagnoses.
• Document a follow-up plan beyond just checking the box of a patient’s return date.
• Be wary of cutting and pasting too quickly or relying on the template as a standard of care instead of thoughtful application of the evidence.
• Learn the entry fields for diagnosis codes and for medications and their route of administration.
• Double check that you’re clicking the correct patient, medication, and date of service.
• To prevent data breaches, including HIPAA violations, set up different levels of employee access to EMRs and never share your password.
• Narrative notes should be customized and included, even if the records ask many yes/no questions.
• Keep consistent records. Inconsistency in record keeping is one of the fastest ways to end up in litigation, Dr. Lessin warned. Separation of staff duties in filling out different parts of the EMR, failure to review templates, and “hybrid” charts for which the paper and electronic records don’t match are among the biggest risks for inconsistencies.
• Devise a method for tracking and following up with nonresponsive specialists and with patients, checking on their compliance and unique health care needs. “If a patient with diabetes comes in three times between October and February and you don’t give them a flu shot, then when they get the flu, whose fault is that?” he said. “You need some way to track high-risk patients who need immunizations.”
• Enter notes in a timely fashion – knowing that audits will show time and date of entries – and only use addenda to modify notes.
“If you’re going to make any changes in the medical record, you need to do it as an addendum,” Dr. Lessin said. And, of course, never try to erase a record. Even accidental alterations of records that aren’t following the rules can look very bad, he said.
Dr. Lessin is a principal with Physician Integration Consultants in Atlanta.