Defective Medical Records – a Real Concern

by | Published on Aug 23, 2013 | Medical Record Review

A major concern at present is whether the electronic medical record systems available now can provide accurate healthcare data. There are class action suits involving EHR manufacturers, which is indeed a matter of grave concern.

With the drive for EHR implementation, physicians are under tremendous pressure having to enter patient details into the medical records in a timely manner. Work pressure forces many physicians to utilize the copy-paste feature available in the EHR system, which can result in copying outdated or inaccurate information. This can compromise patient safety and lead to undesirable outcomes. The main concerns physicians have regarding EHR are software and design flaws, and the lack on interoperability among various electronic health record systems. When there is no co-ordination among the EHR systems, potential threats include missing/incomplete information. This poses the danger of erratic diagnosis and treatment.

Erratic medical records are a major issue when it comes to medical litigation that relies entirely on the facts that can be extracted from patient medical records. Such records can seriously hamper justice.

Taking into consideration the possibility of erratic EHR systems, the Department of Health and Human Services’ Office of the National Coordinator for Health Information Technology has facilitated confidential reporting of IT-related adverse events. This is with a view to improve patient safety. As a certifying body for electronic health records technology, the ONC will strive to ensure that EHRs make it easy to report patient safety events and hazards via common reporting formats developed by the Agency for Healthcare Research and Quality. This kind of confidential reporting is expected to help understand common problems associated with EHRs, their frequency of occurrence and how they can be set right. We can only hope that the “bugs” and “glitches” associated with electronic health records are effectively eliminated and patient safety safeguarded.

Discover our medical record review solutions and partner with us for your next case.

Related Posts

Best Practices for Conducting Thorough Legal Medical Record Reviews

Best Practices for Conducting Thorough Legal Medical Record Reviews

According to a John Hopkins Study, more than a quarter million deaths occur as a result of medical errors, making it the third leading cause of death in the United States, after heart disease and cancer. Regardless of whether the requirement is for malpractice cases,...

Understanding Slip and Fall Workers’ Compensation

Understanding Slip and Fall Workers’ Compensation

Slip and fall workers’ compensation benefits may be available to workers who sustain a slip and fall injury while doing a work-related task. Such injuries are among the most common workplace injuries and often entails considerable medical expenses and lost wages....

Understanding Narrative Summaries in Medical Record Review

Understanding Narrative Summaries in Medical Record Review

According to a 2023 report by the National Institutes of Health (NIH), around 80% of a patient’s healthcare information is disorganized, making it challenging for non-medical professionals to navigate the records. A well-crafted narrative summary is what makes medical...