Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.
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3 8 O U T P AT I E N T S U R G E R Y M A G A Z I N E O N L I N E | J U LY 2 0 1 5 The electronic medical record (EMR) is touted as one of the best new additions to medical record keeping due to its time-saving abili- ties, its ease of transferring records and its tailor-made templates, which should make it all but impossible to fail to document an impor- tant step in patient care. And, yes, recording the detailed care of the patient can be your best friend in the event of a malpractice case. However, some of the very features that make the EMR so quick and easy to use make it potentially dangerous with a couple of pitfalls. Pitfall: Altering records after the fact A physician may use the EMR system perfectly — until she gets the whiff of a potential lawsuit. Take, for example, the gynecologist who places an intrauterine device (IUD) into a patient — a procedure she has performed hundreds of times. The doctor is well-versed with the EMR and chooses to write a freehand note in the chart instead of using a ready-made template designed for IUD insertion. She writes that the uterus sounded to 9.5 cm prior to placement, and that the patient complained of pain upon insertion. Despite these abnormali- ties, the doctor doesn't suspect perforation of the uterus and sends the patient home. The gynecologist later hears that the patient went to the ER shortly after the procedure. The IUD was in her abdominal cavity; she was diagnosed with a uterine perforation. After learning this, the nervous doc goes back into the patient's EMR and rewrites the notes using the standard template to show that everything was routine — the uterus sounded at 7.0 cm and the patient did not complain of pain. The patient later sues the gynecologist, and at deposition the doctor claims that she did not access or alter the charts in any way after the day of the procedure. This is a slam dunk for the plaintiff. Why? Because typically after stating this for the official record, the patient's 1 M E D I C A L M A L P R A C T I C E