Articles: Medical Records
Computerized Medical Records
 The
following material is excerpted from Iyer, Patricia, "Computerized
Medical Records" in the forthcoming book edited by
Iyer, P., Levin, B., and Shea, M.A., Medical
Legal Aspects of Medical Records, to be published
by Lawyers and Judges Publishing Company. Contact us at
908-788-8227 to pre-order the book.
The
computerization of charting has become one of the strongest
trends in documentation throughout the United States and
Canada. Agencies of all sizes and descriptions are developing
or purchasing computerized information systems that support
medical practice, although many are reluctant to give up
the security of a paper record with manually entered information.
Paper charts are familiar to its users, portable, flexible
and rapidly browsed.1
It may become impossible to replicate a lost paper record.
Undetected tampering with paper records may occur, and it
is impossible to determine who reviewed a paper chart. It
may be difficult to find information within a paper chart.
Handwritten charts are often illegible, increasing the risk
of medical errors due to misinterpretation of or inaccessible
data and the intricacies of litigation.
Benefits
to the attorney of computerized documentation
Computerization
of documentation provides some benefits for those involved
in litigation.
•
One of the most obvious benefits is the creation of legible
records. Computer-printed records are completely legible,
therefore eliminating the confusion caused by guessing at
the meaning of handwritten words.
•
The identities of the healthcare providers are easy to determine,
as each entry is followed by either initials or a full name
and status (MD, RN, LPN and so on). If the entry is followed
by initials, somewhere else in the document the person's
full name will appear.
•
The programs which incorporate the facility's standards
of care prompt the healthcare provider to enter the essential
information. For example, an admission assessment would
include information that would identify the patient's risk
for skin breakdown or for a fall. This type of prompting
focuses the nurse's attention on key clinical issues and
reminds the nurse to collect and enter the data that would
fulfill the standard of care.
•
It is possible to determine who has accessed an electronic
chart. For example, Registered Nurse Charles Cullen, who
confessed to killing many patients, was finally caught in
2003 through the use of computers. His excessive use of
digoxin, a medication used to kill his victims, was preceded
by accessing medical records of patients to whom he was
not assigned. The digoxin was stored in a computerized drug
dispensing cart, which recorded his removal of the drug.
•
Tampering with the medical record is much more difficult
to do with an electronic system. Software programs contain
a way to correct mistaken entries, such as an incorrect
entry, misspelled word, or typographical error. A clock
embedded in the software program indicates the precise time
and date of an entry, which makes it impossible to backdate
information to make it look as if it was entered earlier.
Software programs contain a feature that makes the entry
unalterable after a certain time or event. The typical method
is to make the entry unchangeable once it is authenticated.
There is a regularly scheduled backup time to store data,
making it impossible for someone to delete previous entries
once they are saved.
Problems
for the attorney associated with computerization of documentation
•
Data may be inaccurate and widely spread. Misinformation
about a patient is difficult to correct as electronic health
records are shared around the medical community.2
•
Failure to authenticate a medical record may permit alterations
of data after the entry should have become permanent. For
example, a nurse who fails to authenticate nursing notes
until the end of an eight hour shift may make changes after
an event has occurred. A software solution that deals with
this issue may include making an entry unalterable after
a certain period of time, such as within a few minutes.
On the other hand, an operative report may not be considered
permanent for one or more days, thereby giving the physician
the opportunity to review and correct what was previously
dictated.3
The attorney should be alert to the possibility that the
original dictation was altered or a substitute operative
report was prepared.
•
Some electronic medical records have the capability of assembling
and printing out all of the data related to specific aspects
of the patient’s care. For example, all of the nursing
entries referring to elimination, skin integrity, or patient
education are collected and printed out in chronological
form. It becomes difficult for the reviewer to identify
a picture of the patient’s condition at any one point
in time.
•
A common complaint about computerized documentation is that
some of the individuality of charting is lost. Since the
same stock phrases are used over and over, after awhile
the charting on the patients ends up sounding alike. While
this is also a potential pattern in manual documentation,
it is more clearly evident with computerized documentation.
Although the software programs usually allow free text entry
(narrative notes), many healthcare providers either don't
know how to type or don't take the time to create free text
entries. This can create frustration for the attorney trying
to obtain a clear picture of the patient's status. The assistance
of a legal nurse consultant may be invaluable in deciphering
data and assembling a chronology of care.
•
Free text entries are brief and may not adequately describe
an incident or series of events leading up to an emergency.
This greatly increases the difficulty in analyzing liability
in medical malpractice cases.
•
The adage “garbage in, garbage out” applies
to the computer medical record just as it does to other
aspects of computer programming. Incidents may increasingly
occur in which clearly inaccurate information has worked
its way into the medical record, but has not been questioned
by healthcare professionals because computerized information
is perceived to be infallible. No machine can replace a
healthcare professional who can critically evaluate patient
data and question information that does not make sense.
Attorneys and healthcare personnel must guard against the
temptation to deify the computer, keeping in mind that the
computer is only a tool to enhance documentation.
References
1. (back
to article)
Bradley, V, "Innovative informatics: CPR- computerized
patient record", Journal of Emergency Nursing,
p. 230, June 1994
2.
(back
to article)
id
3.
(back to article)
Jergesen, A., "Alteration of electronic medical
records", physicianlawalert.com/publications/articles/PLA_Conf_eHealth_02.html,
accessed 2/15/04
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