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detailed procedure note so the entire record retains credibility.
While detailed notes are important, your EMR templates also play a
role in your success. Many EMRs have "normal" screens that are easy
to fill out. To record any abnormalities, they may need to use a pop-up
screen or drop-down menu. To combat this, work with your EMR ven-
dor to make your system as intuitive to use as possible. Also make
sure staff and physicians are well-trained not only in how to use the
"normal" templates, but also the additional screens and pop-ups.
Encourage them to freely enter detailed text for each patient.
Don't mess up
I'm often asked what to do to avoid being sued. Other than the wise-
guy answer of "don't mess up," consider what ethical actions you can
take now to make defending a medical malpractice case easier.
Basically, that comes down to being very familiar with your EMR sys-
tem and always creating an accurate chart that clearly documents all
of the unique findings for each patient. OSM
Dr. Molinaro (pmolinaro@fransenandmolinaro.com) is a practicing physician
and an attorney at Fransen & Molinaro in Corona, Calif.