Health Records website - Electronic Medical Record issue
Electronic Medical Record. Medical records keep track of a patient's health history. They serve as a proper legal document the patient is entitled to read. A medical record can be maintained in two ways: either by hand-written documents (which is time-consuming, prone to error and take a lot of storage space), or by electronic medical records. Electronic medical records, under the law, cannot be seen by a third party, with some specific exceptions, without your permission. That way, nobody will be able to unfairly charge you for various things like insurance. Privacy is a big concern for most people; thus this law of privacy.
Electronic medical records come with a lot of advantages. They have ultimately replace (or will replace) hard-copy records of medical issues. That way your records can be accessed anywhere in the world, depending on where you receive the treatment you need. The advantages include:
1. Electronic medical records are more flawless than those written manually.
2. Record of medical history written electronically can store more information than those written by hand.
3. Electronic medical records are more accurate, and easier to maintain.
4. They save a lot of time, as the required medical data is easily obtainable by the push of a button.
5. Privacy is best maintained by electronically stored medical data. When it is written by hand there is always the possibility of a lack of privacy.
6. Electronic medical records help a lot when it comes to the question of storage and maintenance of the medical data.
The application of sophisticated software has facilitated the better maintenance of such medical records.
Electronic medical records are currently the new trend that most physicians are heading towards. This practice has been a way for physicians to improve the care of patients, reducing costs and to avoid medical mistakes. On the other hand this new technology may come with some legal risks.
There are many benefits to using a system of electronic medical records which include being able to read the record without having to worry about sloppy handwriting, immediate access to the records, built-in safety features and also it would reduce the risk of a physician prescribing a medication that the patient is allergic to.
However EMR's may create some problems. Some physicians could be sloppy typists and the fact that some physicians will most likely take home the laptop and that poses a problem with the patients confidentiality which could result in a HIPAA violation. So with this in mind it's good that physicians or any other healthcare worker that has access to patient records pay attention to the risks that are important to consider.
Here of 5 of the 10 ways to reduce legal risks.
1. Implement personal and practice policies regarding electronic order entry
Be careful when reading messages from the system. If there is a multitude of emails being sent often, unsubscribe these unnecessary emails.
2. Develop a system and policies of what to do when an order occurs when the physician is not at his or her workstation or if the system is temporarily down
There must be in place a system of how to handle this situation if it happens. For a period of time, physicians may have to go back to pen and paper to record important information for the patients record and later enter that information into the electronic medical record.
3. Print out progress notes from time to time and evaluate the accuracy of the record
These records should then be evaluated to see if they are easy to follow and read. They should also be evaluated to see if the record accurately show what the physician did for the patient.
4. Back-up the records. Make sure to check the back-up method frequently.
It's important to make sure the files are backed up everyday. If a physician fails to do this, they could possibly lose patient records and have no other way of showing what the physician has done for the patient and also no documentation in the event the physician is sued.
5. Install virus protection software on server and workstation computers
This is extremely important to install on the computers that are being used for electronic medical record technology in order to avoid a virus infiltrating your system which could be very damaging.
As was discussed in part one of this article the risks of using the technology of electronic medical records shows many things that physicians should be aware of and also how to reduce legal risks. We will continue on with this article with five other
Physicians should make sure to sign off the record or log out of the system
This practice is extremely important so that if a physician does not sign out and another physician continues under his or her log in name. This can create a problem because the bill could be submitted under the wrong physicians name. If this were to happen an insurance company can ask for a refund of payment if a medical record is submitted during an audit.
Understand how the system records who is accessing and writing in the record
There should be a system in place where if one is accessing the record but after a period of inactivity an automatic time-out occurs. If a physician needs to make changes or add to a record this should be done at the end of the day but there should be a time period in which the record should lock. In the case of changes being made, a new entry should be noted and it should be clearly written as an addendum to the record with the date of which this change or addition was made, the reason why the change or additional information was added and also at the end of the entry should be an electronic signature to verify the person who made the changes.
Print out a note from time to time to be sure your entries are in your name and record the time of the medical record entry
The past some physicians have had the habit of entering in the patients record in the era of pen and paper method, to record things that haven't happened yet. One example could be that a physician records a date of a cesarean section but that actually hasn't happened yet. So this would have to be entered as a notation with the actual date of when it was entered instead of in the future.
Make sure that only appropriate staff members have access to the records
There should be a protocol in place in case of a security breach from a staff member or other person. There should be a password that is protected when the person or persons that have authorization to log in. Having an automatic sign-out feature is also a protection in case the physician should forget to long out.
Protect records from inappropriate viewing by setting up screensavers and require a password for reentry
Having this feature helps if ever the laptop or computer is left in a room unattended.
Electronic Medical Record. Medical records keep track of a patient's health history. They serve as a proper legal document the patient is entitled to read. A medical record can be maintained in two ways: either by hand-written documents (which is time-consuming, prone to error and take a lot of storage space), or by electronic medical records. Electronic medical records, under the law, cannot be seen by a third party, with some specific exceptions, without your permission. That way, nobody will be able to unfairly charge you for various things like insurance. Privacy is a big concern for most people; thus this law of privacy.
1. Electronic medical records are more flawless than those written manually.
2. Record of medical history written electronically can store more information than those written by hand.
3. Electronic medical records are more accurate, and easier to maintain.
4. They save a lot of time, as the required medical data is easily obtainable by the push of a button.
5. Privacy is best maintained by electronically stored medical data. When it is written by hand there is always the possibility of a lack of privacy.
6. Electronic medical records help a lot when it comes to the question of storage and maintenance of the medical data.
The application of sophisticated software has facilitated the better maintenance of such medical records.
Electronic medical records are currently the new trend that most physicians are heading towards. This practice has been a way for physicians to improve the care of patients, reducing costs and to avoid medical mistakes. On the other hand this new technology may come with some legal risks.
There are many benefits to using a system of electronic medical records which include being able to read the record without having to worry about sloppy handwriting, immediate access to the records, built-in safety features and also it would reduce the risk of a physician prescribing a medication that the patient is allergic to.
However EMR's may create some problems. Some physicians could be sloppy typists and the fact that some physicians will most likely take home the laptop and that poses a problem with the patients confidentiality which could result in a HIPAA violation. So with this in mind it's good that physicians or any other healthcare worker that has access to patient records pay attention to the risks that are important to consider.
Here of 5 of the 10 ways to reduce legal risks.
1. Implement personal and practice policies regarding electronic order entry
Be careful when reading messages from the system. If there is a multitude of emails being sent often, unsubscribe these unnecessary emails.
2. Develop a system and policies of what to do when an order occurs when the physician is not at his or her workstation or if the system is temporarily down
There must be in place a system of how to handle this situation if it happens. For a period of time, physicians may have to go back to pen and paper to record important information for the patients record and later enter that information into the electronic medical record.
3. Print out progress notes from time to time and evaluate the accuracy of the record
These records should then be evaluated to see if they are easy to follow and read. They should also be evaluated to see if the record accurately show what the physician did for the patient.
4. Back-up the records. Make sure to check the back-up method frequently.
It's important to make sure the files are backed up everyday. If a physician fails to do this, they could possibly lose patient records and have no other way of showing what the physician has done for the patient and also no documentation in the event the physician is sued.
5. Install virus protection software on server and workstation computers
This is extremely important to install on the computers that are being used for electronic medical record technology in order to avoid a virus infiltrating your system which could be very damaging.
As was discussed in part one of this article the risks of using the technology of electronic medical records shows many things that physicians should be aware of and also how to reduce legal risks. We will continue on with this article with five other
Physicians should make sure to sign off the record or log out of the system
This practice is extremely important so that if a physician does not sign out and another physician continues under his or her log in name. This can create a problem because the bill could be submitted under the wrong physicians name. If this were to happen an insurance company can ask for a refund of payment if a medical record is submitted during an audit.
Understand how the system records who is accessing and writing in the record
There should be a system in place where if one is accessing the record but after a period of inactivity an automatic time-out occurs. If a physician needs to make changes or add to a record this should be done at the end of the day but there should be a time period in which the record should lock. In the case of changes being made, a new entry should be noted and it should be clearly written as an addendum to the record with the date of which this change or addition was made, the reason why the change or additional information was added and also at the end of the entry should be an electronic signature to verify the person who made the changes.
Print out a note from time to time to be sure your entries are in your name and record the time of the medical record entry
The past some physicians have had the habit of entering in the patients record in the era of pen and paper method, to record things that haven't happened yet. One example could be that a physician records a date of a cesarean section but that actually hasn't happened yet. So this would have to be entered as a notation with the actual date of when it was entered instead of in the future.
Make sure that only appropriate staff members have access to the records
There should be a protocol in place in case of a security breach from a staff member or other person. There should be a password that is protected when the person or persons that have authorization to log in. Having an automatic sign-out feature is also a protection in case the physician should forget to long out.
Protect records from inappropriate viewing by setting up screensavers and require a password for reentry
Having this feature helps if ever the laptop or computer is left in a room unattended.
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