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attorney will show the jury the EMR's access logs that make it clear
the patient's record was altered. In many states, the attorney can then
legally tell the jury to assume that everything the doctor says is a lie,
making a successful defense all but impossible.
Had the gynecologist used her true and correct record, the case then
would be based on expert witness testimony as to whether the doctor
sounded the uterus properly and if she should have recognized the per-
foration — which makes defense at least possible. Obviously, you
should stress to your physicians and staff that altering records after
procedures is a big no-no. With EMRs, it's that much easier to deter-
mine if something has been changed. As such, make sure that you have
a strict policy in place against altering records after a patient has left
your facility.
Pitfall: Skimping on details
Keep in mind that detail still matters when working with EMRs.
Remind staff and physicians, especially those used to working with
handwritten records, that just because the record is electronic doesn't
mean it should be any less detailed. When a doctor takes the time to
handwrite procedure notes, it provides insight into exactly what hap-
pened. The same goes for an EMR.
Another common problem is that many EMR users only stick to pre-
chosen words and check-off boxes from a template when entering
patient records. If this record is entered in court, it may show a lack
of attention to detail.
This is especially apparent in procedure notes written by surgeons
after a completed case. When a surgeon dictates a procedure note, he
uses a variety of words tailored for the patient and adds details as he
speaks. This requires little effort, but can be assumed to be correct
since it offers a more detailed look at a particular procedure.
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