EHRs and medicolegal risk: How they help, when they could hurt

How to use EHRs responsibly without increasing risk

Good communication between patient and provider is paramount in the provision of quality medical care. Adherence to evidence-based standards with thorough documentation always serves the best interests of both patients and providers. The EHR can facilitate this process.

Our recommendations for appropriate use of your EHR include:

• Spend time learning the ins and outs of your particular EHR, and make sure your staff does the same. This will help reduce the likelihood that errors will be introduced into the record and ensure consistent use.
• Use individual sign-ons for anyone involved in data entry. This step facilitates the identification of users responsible for inaccurate use or errors, so that the situation can be addressed efficiently.
• Do not let third parties enter or manipulate data. This could jeopardize patient privacy, as well as the integrity of the record itself.
• Track all data entry on a regular basis. The frequency of tracking should be a function of routine as well as clinical circumstance. All new data from the previous interval should be reviewed at the time of the subsequent visit in order to direct care and ensure proper data entry.

Because of the considerable risk of liability claims in ObGyn practice, it is critical that the medical record accurately and precisely reflects the circumstances of each case. The EHR can be an effective and useful tool to document what occurred (and when) in a clinical scenario.¹⁸ As with all medical records, completeness and accuracy are the first and best defense against allegations of medical malpractice.