Maintaining electronic medical records are an integral part of administering any healthcare facility. Unlike most other professions and disciplines which do not necessarily require constant record keeping, they do constitute a key factor in a medical practice because other than the effects of the doctor’s therapeutic on the patient, the medical records (EHR) provide a real -time documentation as to how the patient was cared for by his/her physician, and the efficacy of that care.
One reason they are so important is because they provide an ongoing opportunity to stay abreast of the goings on within healthcare facility itself. Hospital risk management departments are responsible for investigating instances of malpractice to analyze what went wrong and how to prevent recurrences. In such cases, verbal clarification is insufficient and occasionally misleading. Health care is often complex and highly detailed and the average practitioner can not remember each of the steps they took in the care of any given patient. Hence there is significance to the timing of the creation of the record, namely the issue should be recorded in real time.
Another aspect of administrative responsibility served by accurate medical records is maintaining a protocol of what transpired. In instances where medical treatment results in patient dissatisfaction, and the patient claims malpractice, the medical record serves as the organization’s fundamental defense of its actions in the event of a judicial proceeding.
Electronic medical records are so important that the courts accept them as prima fascia evidence as to how the case was handled, without supporting evidence – in all but very unusual cases. So, while from a medical standpoint maintaining records may not be necessary, the law requires that they be kept.
For example, where a question arises, a physician is expected to consult with a colleague. A consultation can be via correspondence or oral. A doctor who consults with a colleague verbally without documenting the contents of the consult in writing would find it difficult to prove that he did actually consult.
Another example: When a doctor has a patient who describes symptoms, he has to evaluate and compare his diagnosis against the differential diagnosis. Keeping a record of the differential diagnoses would substantiate the physician’s claim that all the possible options were considered. It is necessary to make a record of this type even if the differential diagnosis was made under duress or in an emergency. In the absence of an electronic medical record system, there is really no other way to verify that the doctor considered alternate approaches. In fact a doctor who did consider alternate options and erred in his judgment would in all probability avoid liability in a malpractice suit since the medical record would serve as evidence as to how he approached the issue and why this approach was of questionable medical value.
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In the absence of a medical record software, a case could be made for the delivery of deleterious medical care. In any malpractice claim, the burden of proof is on the petitioner (patient). However where there is an absence of carefully maintained medical records, or where critical data is missing, the burden of proof is transferred to the defendant (the physician of record). In the event, the doctor now has to prove that he was not negligent and that the care he offered meets with the standard of recognized medical care – despite his failure to register the sequence of his treatment into the electronic medical record. In the event, it is very difficult for the doctor to prove his innocence where he was negligent in providing adequate documentation as to his actions.
Where there is any suspicion regarding medical malpractice, the first step is to collect all the relevant medical and patient care records. These serve as the basis for the legal team and a professional medical peer evaluation to evaluate the facts and decide if a legal proceeding is called for.
This in brief is an explanation as to the value of maintaining electronic medical records.
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Practice Information
