EHR Best Practices — Lessons Learned in Litigation

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

Scanning

• 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.

Follow-Up

• 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.

Security

• 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 library.ahima.org. (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 healthit.gov. (accessed 6/20/17)