Page 19 - Part Two Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

Consider the following case:

CASE STUDY

A nephrologist, over the course of several office visits, incorrectly
carried over erroneous documentation suggesting a positive

study for an enlarging renal mass, which was the basis for a
radical nephrectomy. The post-op pathology report revealed no

such cancer. During the deposition, the physician admitted to
the documentation errors that were the result of the “copy and

paste” function of the EHR system. While the physician’s failure

to review the study prior to taking the patient into surgery was
difficult to defend, the documentation errors called the entire

record, as well as the physician’s credibility, into question.

Pitfall #3 – Auto-Population

Auto-population allows the EHR system to pre-fill information in
specific areas of the medical record as a means of creating a

short-cut or improving the efficiency of the documentation

process. The practitioner must be aware of those areas of the

medical record that are auto-populated in order to know what

information will need to be reviewed and verified prior to signing
the note.

The first type of auto-population is found in the use of templates.

Most EHR systems contain check boxes for the practitioner to use

to select symptoms and findings that reflect the patient’s condition.
When templates are constructed which are diagnosis-specific, the

check boxes may be pre-selected, based on the template selected.

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