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SVMIC Risk Basics: Surgical Practice
include a note that describes what took place, what you were
thinking, and what advice you gave, including any follow-up
recommendations.
Electronic Health Records
Although the use of an electronic health record can offer many
benefits such as clinical decision support tools, improved
legibility, and interoperability, there continue to be risk issues.
The most significant risk issue is with copy and paste. If using
an EHR, review and correct all documentation that may have
auto-populated or been carried over from a previous visit to
ensure it is an accurate reflection of the current office visit
assessment.
The use of a copy and paste capability to create the new note
from the old one is fraught with potential risk. Copying
information from a prior note and pasting it into a new note
may result in notes which are identical, perpetuate outdated or
incorrect information, and produce voluminous progress notes
that obscure important new information. In litigation, repetition
of identical notes, including errors in those notes, will raise
questions about whether or not the physician reviewed the
note for accuracy when the accuracy of a medical record is
questioned the trustworthiness of any portion of that record is
then also questioned.
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