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EHR Best Practices — Lessons Learned in Litigation

June 22, 2017

NORCAL's Risk Management Specialists offer the following electronic health record (EHR) best practices based on lessons learned in litigation.


  • Train staff on scanning policies and procedures.
  • Stress accuracy, not just efficiency.
  • Consider periodic chart reviews to ensure that information has been scanned into the correct chart.


  • Utilize a tracking system to ensure receipt and follow-up on labs, referrals, etc.
  • Ensure consistent workflow for handling lab reports and other information received from outside the clinic.
  • Ultimately, it is the clinician’s responsibility to ensure appropriate follow-up. The clinician cannot delegate this to medical assistants or other staff.

Copying and Pasting

  • Create a copy and paste policy and train everyone on it.
  • Consider periodic chart reviews to look for inappropriate use of copying and pasting.
  • Use an EHR audit trail to track any changes made to the record.


  • Create and educate staff and enforce policies on:
    • Use of their own username and password to access the EHR system
    • Timeframes for when patient encounters must be signed off on and locked
    • Confidentiality and security (notify patients of this policy as well)
    • Employees who access patient information without a legitimate business reason to do so
  • Create appropriate levels of access restrictions in the system.
  • Ensure that computer screens are not visible to the public.
  • Never leave a computer that you are logged into unattended without being locked.
  • Never share your password with other staff.
  • After data entry or record review, close the patient’s record.
  • Ensure that you have the proper level of encryption and HIPAA-required security in your EHR.
  • Create a back-up and disaster recovery plan.
  • Ensure that your EHR can produce an audit log.

Data Integrity

  • Watch for inaccurate chart entries as a result of templates or copying/pasting.
  • Review all data to ensure its accuracy before signing off.
  • Consider periodically printing out chart entries to see if they are accurate and easy to understand.

Prescribing From An EHR

  • Be careful when using drop-down boxes or pre-populated doses of medications.
  • Find out if the EHR software recognizes off-label doses. If not, work with the vendor to modify the system.
  • Ensure that only one chart is open at a time.
  • Adjust EHR alerts to make sense for your clinic.
    • Do not bypass alerts without a process.
    • Document the rationale for any bypass in the EHR.
  • Ensure that interfaces with outside systems are working properly.

Additional Resources

American Health Information Management Association (AHIMA): Sample policies and procedures for members at (accessed 6/20/17)

SAFER EHR Guides (created by Office of National Coordinator for Health IT): Self-assessments, worksheets and tips to optimize EHRs at (accessed 6/20/17)

This content from Claims Rx

Filed under: Electronic Health Records, Best Practices, Practice Manager, Physician



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