Page 34 - APP Collaboration - Assessing the Risk (Part Two)

SVMIC Advanced Practice Provider Collaboration: Assessing the Risk

The first thing to remember is that the audit trail is discoverable
and is tracking and timestamping electronic access and

activities. The timeline is no longer a guessing game. During
discovery, lawyers may request printed copies of the EHR and

also copies in native format, which shows how the data was
used. For example, were pharmacy alerts and prompts followed

or overridden?

This audit trail will include logon and logoff times, what was

reviewed and for how long (eight seconds or eight minutes
spent on an image report), what changes or additions were

made, and crucially, when the changes were made. Smartphone
and e-mail records are also discoverable.

Assume all your activity on any electronic device or

equipment is discoverable.

Let’s look at some best practices with your EHR documentation

to reduce risk:

• Don’t have more than one patient chart opened at the
same time.

• Avoid “identical” office notes. Include free text in your notes
to explain your thought process and plan, even if it’s a

few brief sentences. Remember those free text comments
could save you later in a deposition.

• Keep the notes concise by not including all routine lab
results or vital signs in the notes. Importing all the lab work

into an office note, can turn a brief office visit into a three-
page office note.

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