Pros And Cons Of Electronic Medical Record
ARTICLE #9
Legal Concerns Regarding Medical Record Alteration:
The Proof is in the Metadata
From Coverys Risk Management
(Timothy Malec, Manager, Claims)
With the advent of new technological systems and the passage of the Patient Protection and Affordable Healthcare Act, electronic medical records have been widely adopted by many healthcare organizations. While there are many benefits to electronic medical records, such as better access to patient data and improved preventive health, there are also issues that arise due to the application of this technology.
Particularly when it comes to medical malpractice litigation, problems emerge when healthcare providers don’t understand the implications of their actions, like accessing and changing
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According to an article published by Professional Liability Advocate, “The metadata … compiled into an audit trail … shows the date, time and user who accessed a patient’s chart. It even shows whether the user created or added to an existing record.” If an electronic medical record is altered or amended without indicating that the changes are a late entry, the plaintiff’s attorney will find out. As seen in the example above, this results in negative outcomes for both the case’s defense and the healthcare provider’s …show more content…
Even the simple viewing of electronic medical records without adding or subtracting anything from the record can be problematic. Such viewings can be discovered during an audit and can open the door for a plaintiff’s attorney to suggest possible record tampering, even if that was not your intention.
Specify the reason for any changes made to a record, from addenda to late entries. In paper records, date, time, and initial the late entry. For electronic records (EMRs), work with your organization’s administration and the software vendor to determine the method that works best in your EMR.
Refrain from accessing the EMR until you speak to your professional liability insurer if you are sued or a claim is brought against you. If an attorney is retained on your behalf, he or she can and should obtain the records for you.
When a situation with a patient becomes legal, it’s important to understand that there are two records that will be considered: the patient’s actual medical records, and the digital artifacts represented by the metadata—in other words, the record of how the patient’s information was kept, stored, and changed over time. Your commitment to maintaining thorough, timely records that are meticulously maintained and updated will go a long way towards protecting you and your organization in any legal issues that may
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