--- title: EHR Best Practices — Lessons Learned in Litigation description: Best practices for electronic health record (EHR) use based on lessons learned in medical liability claims litigation. image: https://files.norcal-group.com/hubfs/medical-maplractice-lawyer-gavel-scales_social.jpg --- - [Sign In](https://secure.proassurance.com?hsLang=en-us) - g Search Site [Contact Us](https://www.proassurance.com/contact-us/?hsLang=en-us): **844-466-7225** [![PRA-MMI-Logo®-RGB](https://www.norcal-group.com/hs-fs/hubfs/PRA-MMI-Logo%C2%AE-RGB.png?width=215&height=62&name=PRA-MMI-Logo%C2%AE-RGB.png)](https://www.norcal-group.com?hsLang=en-us)   - [About](https://norcal-group.com/about) - [About Us](https://norcal-group.com/about) - [Coverages](https://norcal-group.com/state) - [Claims](https://www.proassurance.com/report-a-claim/) - [Resources](https://www.norcal-group.com/resources) - [HIPAA Resources](https://proassurance.com/hipaa) - [Website Accessibility](https://proassurance.com/accessibility) - [Pay](https://www.norcal-group.com/pay) ## [Resource Library](https://www.norcal-group.com/library?hsLang=en-us) # EHR Best Practices — Lessons Learned in Litigation June 22, 2017 - [Tweet](https://twitter.com/share) NORCAL's Risk Management Specialists offer the following electronic health record (EHR) best practices based on lessons learned in litigation. ## ![medical maplractice lawyer gavel scales](https://files.norcal-group.com/hubfs/medical-maplractice-lawyer-gavel-scales_social.jpg)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 ### More Information About Optimizing Your [EHR](https://www.norcal-group.com/library/optimize-your-ehr-to-manage-risks-case-studies-and-best-practices?hsLang=en-us) to Manage Risks - [Optimize Your EHR to Manage Risks: Case Studies and Best Practices](https://www.norcal-group.com/library/optimize-your-ehr-to-manage-risks-case-studies-and-best-practices?hsLang=en-us) - [Issues with Identical and Default Text When Using EHR Efficiency Tools](https://www.norcal-group.com/library/issues-with-identical-and-default-text-when-using-ehr-efficiency-tools?hsLang=en-us) - [Pasted and Template Text In an EHR Leads to Problematic Medical Records](https://www.norcal-group.com/library/pasted-and-template-text-in-an-ehr-leads-to-problematic-medical-records?hsLang=en-us) - [Uncorrected Default Text in an EHR Leads to Defamation Suit](https://www.norcal-group.com/library/uncorrected-default-text-in-an-ehr-leads-to-defamation-suit?hsLang=en-us) - [EHR Integration Problems Contribute to Delayed Diagnosis of Lung Cancer](https://www.norcal-group.com/library/ehr-integration-problems-contribute-to-delayed-diagnosis-of-lung-cancer?hsLang=en-us) - [The Problem with EHR Workarounds](https://www.norcal-group.com/library/the-problem-with-ehr-workarounds?hsLang=en-us) - [Identify and Remedy EHR Liability Risk Issues: Risk Management Strategies](https://www.norcal-group.com/library/identify-and-remedy-ehr-liability-risk-issues-risk-management-strategies?hsLang=en-us) - **EHR Best Practices — Lessons Learned in Litigation** - [Parental Access to Adolescent Patient Portals](https://www.norcal-group.com/library/parental-access-to-adolescent-patient-portals?hsLang=en-us) - [Solutions to Reduce EHR Burdens and Decrease Physician Burnout](https://www.norcal-group.com/wellness/solutions-to-reduce-ehr-burdens-and-decrease-physician-burnout?hsLang=en-us) - 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](http://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](https://www.healthit.gov/safer/). (accessed 6/20/17) This content originally appeared in Claims Rx, our claims-based learning publication. Many releases are available for download in the [Claims Rx Directory](https://www.norcal-group.com/claimsrx?hsLang=en-us). For select releases, eligible insureds will also find instructions for obtaining CME credit. Filed under: [Electronic Health Records](https://www.norcal-group.com/library/topic/electronic-health-records), [Best Practices](https://www.norcal-group.com/library/topic/best-practices), [Practice Manager](https://www.norcal-group.com/library/topic/practice-manager), [Physician](https://www.norcal-group.com/library/topic/physician) ###  Topics  Please select Bad Outcomes & Complications Business Continuity Business Operations Community Health Consultations Cosmetic & Reconstructive Procedures Cultural Competency & Cultural Respect Cybersecurity Diagnosis & Testing Digital Practice Electronic Health Records (EHR) General Liability HIPAA Privacy & Confidentiality Industry Trends Information Security Informed Consent Leadership Litigation & Claims Marketing & Practice Building Medical Errors & Apology Medical Ethics Medical Records & Documentation Medication Errors Opioids Pain Management Patient Communication Patient Relationship Personal Finance & Career Philanthropy & Community Involvement Physician Burnout Physician Ratings Physician Wellness Practice Communication Practice Drift Practice Management Prescribing & Medication Public Relations & Communication Regulation & Compliance Reputation Management Unanticipated Outcomes Vicarious Liability ###  Specialties  Please select Emergency Medicine Family Practice Mental & Behavioral Health Obstetrics & Gynecology Oncology Ophthalmology Orthopedics Pain Management Specialist Pediatrics Plastic & Cosmetic Surgery Radiology ### Recently Added Interested in NORCAL Group? **Contact Your Agent/Broker** or call 844.4NORCAL today * NORCAL Group, now part of ProAssurance, includes NORCAL Insurance Company and its affiliated companies. 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