Positive Outlook - Issue 2.0 - May 2013

By: Texas Medical Liability Trust (TMLT is the only health care liability claim trust created and endorsed by the Texas Medical Association.)

As you adopt new technology in your practice such as the electronic medical record (EMR), be sure to identify and resolve new liability exposures that arise. Texas Medical Liability Trust (TMLT) offers these 10 tips for avoiding documentation pitfalls related to electronic medical records. For more information about each tip, read “Potential Pitfalls: Risk management for the EMR” (PDF) on the TMLT Web site.

  1. Implement a strict policy regarding passwords and security. 

  2. Ensure patient encounter records are locked. 

  3. Be aware that templates can import old or inaccurate information. 

  4. Make sure physician sign-off is clear. 

  5. Review orders or e-mails before signing off with electronic signatures. 

  6. Enable your software’s tracking mechanisms. 

  7. Establish a system to appropriately capture paper and other external clinical documents. 

  8. Make sure complete prescription information is captured in the EMR. 

  9. Ensure records are backed up reliably. 

  10. Make sure the records are complete when providing printed copies.