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The 1996 Health Insurance Portability and Accountability Act (HIPAA) gave patients a right to view and request corrections to their medical records. In the intervening years, the widespread adoption of electronic health records (EHR), patient portals, and smartphone applications have led to an increase in patients accessing their medical records electronically. The digital evolution of the medical record has prompted a number of healthcare professionals and patient safety advocates to promote quicker access to information stored in the EHR.

An online search for the phrase “slip and fall” returns a never-ending wave of advertisements for personal injury lawyers, premises liability insurance products, and risk management services. Absent from this deluge of results is any mention of medical malpractice. Ostensibly, this makes sense. Premises liability and medical malpractice are two separate and distinct categories of negligence.

The reporting of unusual occurrences and adverse events has been a staple of the risk management plan in hospitals and healthcare facilities for many years. Incident and event reports, whether written or oral, are a means of alerting hospital leaders to potential or actual patient harm. These reports are critical to the ongoing identification of risk and the investigation of the circumstances that led to an adverse event. The reports, too, are key to the development of risk mitigation strategies designed to create a safer environment for patients, physicians, and staff. Additionally, the incident report, and the information it contains, is a valuable alert to potentially compensable events and the need for disclosure discussions.

Although electronic health records (EHRs) have many benefits, studies reveal unexpected patient safety and liability risks associated with their use. The speed at which EHR technology is advancing and the speed with which hospitals and medical practices are implementing these systems can partially explain this increased risk exposure.¹ Optimizing an EHR (using it to its full potential) can deflect some of this risk. However, the importance of optimizing an EHR can be overlooked amid the struggle to provide quality patient care while complying with regulations and participating in government incentive programs.²

Adolescent autonomy and privacy are affected by a tangled web of state and federal laws that clinicians are expected to know and abide by. As a rule, adolescent patients cannot give consent for their own medical treatment before they reach the legal age of majority, which, in most states, is 18. The circumstances in which adolescent patients can consent to their own medical treatment vary by state; however, most states have consent exceptions based on an adolescent’s legal status (e.g., married, emancipated) and select medical conditions (“sensitive medical conditions”).