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Medico-Legal Risks & Appropriate Documentation in Medical Records

While electronic medical records have made it easier for healthcare professionals (& lawyers) to review daily progress notes, certain functionality can lead inadvertently to poor care. This is especially given the "cut and paste" functionality that is prevalent in this system.

"Rapid Respond Team (RRT) to Room 150!" Soon after, my pager goes off notifying me of the above RRT on one of the many patients I am proving cross cover for in the wee hours of the morning. The patient appears pale, with a blood pressure of 100/60, heart rate of 110, responsive to painful stimuli but with shallow breathing and pinpoint pupils. As I enter the room, I start asking pertinent questions from the bedside nurses and open the chart to review the latest progress notes on the computer in the room.

I was greeted with a lengthy progress note for the day. There is contradictory information on the patient care timeline.

"The patient will have ERCP done today for bacteremia and cholangitis" and "patient underwent open cholecystectomy today as the patient had persistent fever following ERCP done 2 days ago", but another note stating "patient with persistent bacteremia following ERCP and cholecystectomy that was done last week". One part of the progress note stated that the patient has "normal creatinine today" and a separate sentence states "patient developed acute renal failure today likely due to tubular necrosis and antibiotics". It turned out the RRT is a result of the patient receiving the same amount of prescribed narcotics (morphine), not taking into account the patient's renal failure and resulting in an accidental overdose.

With the advent of electronic medical records (EMR), there are increasing concerns among medical professions on convoluted or redundant information. Copy and paste function in many EMRs has resulted in rambling notes which may not convey accurate, up-to-date information on a patient's current status.

Clinical documentation and progress notes by physicians serve as legal documents. While accurate clinical documentation with the correct "keywords" help with billing and quality, quality documentation is essential for accurate clinical communication. Whereas in the past, medical mistakes are made due to illegible handwriting, EMR is creating a new legal minefield.

It becomes impossible to figure out an accurate chronology of a patient's hospital stay as notes are copied/pasted day after day. In some cases, critical physical exam findings replicated daily, making it unhelpful for clinical care and opening the clinician and hospital to more legal and financial liabilities. For example, a foley catheter was removed on day 2 after surgery, the copied/paste progress note notes that the clinician's physical exam on the day of discharge still reflects that a catheter was still in place. The patient then returned two days after discharge with septic shock due to urinary tract infection and subsequently died. Chart review by an expert witness years later raised concerns about inaccurate documentation about keeping an unnecessary catheter in place resulted in a malpractice suit.

The above real-life scenarios occur daily in hospitals around the United States. Remember the "Less is More" concept, cut and paste only relevant clinical background information, never the same physical exam daily. Do not copy another clinician's notes without attributing credit, yes, plagiarism in medicine can increase medical errors and medical malpractice liability. Stick to the facts, only bring forth relevant information. Never alter medical records after the fact, especially in the event of a lawsuit.

Disclaimer: While every effort has been made to ensure the accuracy of this publication, it is not intended to provide legal advice as individual situations will differ and should be discussed with an expert and/or lawyer.For specific technical or legal advice on the information provided and related topics, please contact the author.

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