Page 11 - Hospitalists - Risks When You're the Doctor in the House (Part Two)

SVMIC Hospitalists - Risks When You’re the Doctor in the House

the issue. As noted earlier, hospitalists are not always consulted

about what system their institution uses. Workarounds are
sometimes created by system users in order to fix perceived

problems in the EHR and to increase efficiency. However, do-it-
yourself workarounds are strongly discouraged as they may very

well lead to the failure of EHR support functions and ultimately
result in patient harm. Although they initially can be expensive,

customized EHR features from the vendor may prevent patient
harm and accordingly be the most cost-effective resolution in

the long-run.

Documentation

The next area of risk identified within the hospitalist claims is
documentation. Maintaining a well-documented medical record,

from both a patient care and a risk management standpoint, is
crucial to both continuity of care and protection from challenges

to the care provided. Documentation issues included untimely or
delayed documentation, inadequate or omitted documentation,

as well as illegible documentation, EHR issues, erroneous
documentation, and inappropriate documentation.

Untimely documentation creates problems for a defense as the
physician’s memory of an event that happened weeks, or even

days, prior to the documentation of it may interfere with the
accuracy of the written words, and attempts to “catch up” often

result in brief, incomplete, or “cookie-cutter” notes. If there was
an intervening event prior to the completion of the notes, all of

the documentation completed after the intervening event may
appear to be self-serving and is subject to exploitation by the

plaintiff.

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