Page 21 - Hospitalists - Risks When You're the Doctor in the House (Part Two)

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

presence of their patients following an examination. Not only

does this result in increased efficiency, but it reinforces patient
instructions, serves as a discipline to refrain from inappropriate

comments, and includes the patient in the evaluation of his
or her health status. Obviously, some degree of discretion is

necessary when using this technique. If dictation is not done
in the patient’s presence, it should be done as soon as it is

practical. Ideally, dictation should take place after each patient
visit. Batch records dictated following a number of patient visits

are more likely to be incomplete and of poorer quality.

Turnaround time for the dictation to be posted in the medical
record should not exceed 48 hours, although 24 hours is ideal.

Delays past 48 hours may cause problems with patients that are
being followed closely. The physician should review and initial

all transcriptions.

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 are risk issues with the use

of an EHR. Some risks are associated with the EHR program
itself, while others are user-generated.

Digital Assists (Shortcuts)

One of the primary causes of erroneous or incomplete records

is the use of digital assists. Every EHR system utilizes digital
assists, or shortcuts, designed to improve efficiency and save

time. When used properly, they serve their intended purpose.
However, if used improperly, the result is a medical record that

is inaccurate and unreliable, containing duplicitous carryover

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