Archive October 2018 XIX, No. 10

Medical Malpractice: Charting Through the EHR MedMal Minefield

5 legal danger zones unique to electronic documentation

Claire Cyriax

Claire Cyriax, DNP, RN, MSN-Ed, LNC, CAPA


CHARTING NEW TERRITORY A danger of dropdown menus, checkboxes and auto-fill is documenting care that was never done.

Who knew dropdown menus and auto-populating fields could be so dangerous? For all the benefits of electronic documentation, EHRs can easily byte us in the emoticon and land us smack in the middle of a medical practice claim if we're not careful to sidestep these 5 pitfalls.

1Auto-populating fields. We've all heard of "Not charted, not done." The ultra-convenient auto-fill/auto-population feature on EHRs has inspired a new charting maxim: "Charted, but not done." Lawsuits claiming that nurses never performed the care that they documented are on the rise.

With autofill, it's all too easy to make charting errors. Typing in a letter or two and hitting enter can bring up a wrong word. As an example, a review of GI system will bring up specific symptoms, such as appetite changes, nausea, vomiting and abdominal pain. If there are symptoms, the auto-population feature can choose those words. Plaintiffs are now claiming that nurses never asked those questions. And it's easy to spot misuse of auto-population by searching for inconsistencies in the record.

Always double check your auto-population when charting and make sure you have the correct information before finalizing the entry. A permanent electronic record of everything that you document exists and you cannot make it go away by crossing out or deleting.

2Copy and paste. The copy-and-paste feature is a convenient way to transfer data, but incorrectly copying the source data or the source of the data could result in an error within a patient's chart. It's easy to see what other nurses have charted before you and you may be tempted to just copy what they documented, especially when nothing has changed. Besides, you assure yourself, you can always review and edit anything that is different from one patient to another.

Another copy-and-paste danger is copying a snippet of a sentence. An expert can easily spot duplicate blocks of information across multiple charts. It suggests that you're taking shortcuts and speaks volumes about your nursing care. In one case, a patient was listed as having a history of "PE" (pulmonary embolism), although the patient denied this. After reviewing the chart, it was found that "PE" had originally been used for "physical exam," but was mistakenly listed under medical history and propagated throughout the chart for years.

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