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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.

medical maplractice lawyer gavel scalesScanning

  • 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)

This content originally appeared in Claims Rx, our claims-based learning publication. Many releases are available for download in the Claims Rx Directory. For select releases, eligible insureds will also find instructions for obtaining CME credit.

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

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