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.

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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.

• BDocument at the time services are provided or as soon as possible after the visit/communication.

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

• Confirm accuracy of drop-down selections before signing the record.

• Ensure that information that automatically populates in the medical record is accurate.

• Review all medication orders for selection errors (drug, dose, frequency, route).

• Use only approved abbreviations, acronyms, and symbols.

• Recognize that templates do not address all elements of care and add narrative.

• Individualize each patient note and expand as needed.

• Correct medical record errors in accordance with federal and state laws, the Privacy and Security Standards under the Health Insurance Portability and Accountability Act (HIPAA), and your organization’s record-keeping guidelines.

• Document late entries or additions to an original entry as an addendum. Include the date and time of the addendum and a brief reason for the addition/late entry. Make it clear that the information you are adding is not part of the original entry.

• Make corrections to clarify inaccuracies as an amendment. Never delete the original entry. The “strikethrough” feature is often used in the EHR/EMR. Date and time the amendment, state a brief reason for the clarification/change, and reference the original note.

• Maintain psychotherapy notes in a separate, secured section of the EMR/EHR to receive additional confidentiality protections under HIPAA.

Don’ts

• Do not add or change a medical record after a claim or safety event has occurred without first consulting an attorney or risk manager.

• Do not copy and paste/clone notes. This practice can undermine the quality of the medical record; may increase the risk of inaccurate, redundant, outdated, and unnecessary information being included; and lead to clinical errors, potential attestation of care provided by another physician, and overbilling of services.

Ensuring documentation integrity through accurate and timely medical recordkeeping helps to improve patient safety and quality of care while reducing the risk of medical and/or civil liability. ■

This information is provided as a risk management resource for Allied World policyholders and should not be construed as legal or clinical advice. This material may not be reproduced or distributed without the express, written permission of Allied World Assurance Company Holdings Ltd., a Fairfax company (“Allied World”). Risk management services are provided by or arranged through AWAC Services Company, a member company of Allied World. © 2021 Allied World Assurance Company Holdings, Ltd. All Rights Reserved.