During EHR documentation, paying close attention and not taking shortcuts can prevent usual errors, which are mostly expensive for physicians.
For instance take this hypothetical case, a sufferer goes into the office of surgeon and, as is common with any medical visit, relays their allergies to medications. The patient claims they are allergic to opioids and that the reaction is chest pain and itching. The patient also has another, rarer, allergy to cortisone, with an extreme reaction of joint swelling, endocrine problems, hives and skin bleaching. Fast-forward few weeks to surgery. The electronic health record that the data was entered into is part of a health system, so the surgical team can pull this data that is available.
The process begins and opioids are provided along with a pain pump, which is usual after this specific kind of surgery. Then, the sufferer goes into respiratory distress and almost dies. It wasn’t the medical team that found the mistake in the chart, in this scenario; it was the sufferer when they went into their medical records with their own password. Rather than seeing the reactions that were given to the intake person at the office of physician, the following things are observed by patient:
Allergies – codeine/opioids – reaction is mild diarrhea; cortisone – reaction is lightly itching.
How did what the sufferer relayed to the member of the physician’s care team get so openly messed up? There are 3 possibilities during using an EHR:
• From the drop down menu, the exact reaction wasn’t available and the staffer either didn’t know or was too lazy to use "other" and make an extra note.
•Wrongly typed information.
•The staffer basically cut and pasted the data from the previous sufferer.
Some of the corrective measures that providers can take to ignore these types of errors and the responsibility that comes from them are as follow:
•Within electronic health record (EHR), activate access controls and other mechanisms which forbid and prevent the use of few functions.
•Rightly train staff, which involves informing them about law suits.
•From one chart to another, never do copy and paste.
In every component of patient chart documentation, precision and accuracy can lead to better results and mitigate liability or responsibility.