Page 51 - OB Risks - Delivering the Goods (Part One)

SVMIC Obstetrics Risks: Delivering the Goods

happen”, and the physician is the usual target. For this reason,
physicians must protect themselves through documentation. At

trial, the most important piece of physical evidence will be
the medical record.

The issues with legibility, alterations, and the use of electronic

health records played a lesser role in the documentation failures
reviewed but are worth mentioning because of the potential

for indefensibility if a physician is not careful to avoid those
mistakes. And, it must also be remembered that the cases we

reviewed had taken many years (some more than 10) to wind
their way through the legal system to a conclusion. Accordingly,

with the advent of EHR, issues relating to the use of shortcuts
such as templates, copy and paste, workarounds, and carryover

information have sharply risen.

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 can be a medical record that is inaccurate, is

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