Do’s and Don’ts of Electronic Documentation

Documentation that is not up to date may lead to errors in patient care, harm to the patient, and potential liability.

The medical record, whether on paper or via an electronic system, is a communication tool used for care coordination and provides up-to-date information regarding the patient’s diagnosis, treatment, and services provided and is used to justify the reimbursement of services, according to the Centers for Medicare and Medicaid Services. The medical record serves as the legal record to provide evidence of adherence to the standard of care as well as federal and state regulations.

Electronic health records (EHR) and electronic medical records (EMR) both contain digital patient health information. An EMR is a digital version of a patient chart that is designed for internal use by one practice, clinic, or hospital and may need to be printed out to share the information. An EHR collects information from all clinicians involved in the patient’s care and can be shared among many settings. Poor documentation in an EMR or EHR can impact patient safety and quality of care, create compliance concerns, and lead to medical and/or civil liability.

Psychiatrists can mitigate liability risk by keeping the following do’s and don’ts in mind when documenting electronically.

Do’s

Be aware of “metadata,” which are computerized data that identify how an electronic document has been manipulated. Metadata can be discovered through an audit trail and identify users who accessed the record; date and time of access; and information viewed, added, deleted, or changed. Metadata may be requested by plaintiff counsel in a malpractice case.

Document pertinent clinical information communicated by phone, email, text, or other electronic means.