Learn the Right Way to Make Corrections in EHR

Learn the Right Way to Make Corrections in HER User errors in electronic health records can be corrected, but this has to be done in the right manner to avoid violation of law.

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Medical transcription outsourcing to an experienced service provider is an effective strategy to ensure accuracy in electronic health records (EHRs).

However, EHR user errors can occur, as a recent study by the Doctors Company revealed. The study found high error rates in EHRs, leading to an increase in EHR-related medical malpractice suits. User errors in EHRs can be corrected, but this has to be done appropriately to avoid violation of law.

Examples of User-related EHR Errors National statistics show that more than 80% of physicians have adopted electronic health records (EHRs). While EHRs are supposed to ensure easier and more accurate record keeping and scheduling, it is disconcerting to note that the Doctors company study revealed that 58% of malpractice claims were related to errors associated with the use of EHRs such as 

data entry errors



copying and pasting progress notes, and



alert fatigue

The study found increases in claims in specialties such as orthopedics, emergency medicine, and obstetrics/gynecology.

In January 2016, an article published by www.thehealthcareblog.com listed case examples of health IT related errors. Here are a few user-related EHR issues cited by the report:  Positive test result for cervical cancer entered into problem list; MD expected it to be in EHR test result section; error not discovered until patient’s visit a year later.  RN entered Haldol order as 5.0 mg instead of 0.5 mg; MD meant to sign off on lab results, but signed off on the wrong order by mistake.

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 Electronically signed discharge order omitted patient’s Coumadin; patient admitted with stroke.  Verbal order for morphine entered without upper limit defined; patient become obtunded and expired.  Results of positive test for C difficile not noticed; 7 day delay in starting treatment.  MD unable to find pathology report in the EHR; called Pathology to get a verbal report, which was a normal result from the wrong patient; real patient died of cancer 3 years later, original report was abnormal.  History copied from a previous note which did not document patient’s amiodarone medication; delayed recognition of amiodarone toxicity.  Alerts on abnormal blood culture ignored.

Amending EHR Records EHR errors can be identified through regular internal audits. However, this has to be done the right way to avoid legal problems and detrimental outcomes. State laws differ on how medical records can be amended. The general rule is that electronic records be maintained "to the same standards" as paper copies. Here are some guidelines on the appropriate way to correct errors in the EHR: Overwriting the initial EHR data, even when it is incorrect, could be considered illegal in a malpractice suit. The right way to go about correcting a mistake in the medical record is to line it out and rewrite it. The American Health Information Management Association (AHIMA) advises:

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 Draw

a

line

through

the

entry,

ensuring

that

the

inaccurate

information is still legible.  Write “error” next to the incorrect entry and provide the reason for the error in the margin or above the note.  Sign and date the entry.  Document the information correctly. Make a narrative entry in the medical record statement stating that an error has been made, and is being corrected. Provide the current date and time and refer back to the incorrect entry.

A Medscape article offers additional guidance on correcting user errors in EHRs:  Flag the amended EHR record to show it has been corrected.  Make sure that the original record or incorrect data is retained and easily accessible.  If the mistake occurs in a laboratory or diagnostic report, the facility director or pathologist should assume responsibility for the narrative entry in the medical record statement indicating that an error has been made.  The original error as well as the correction should be well documented for future reference.  In the case of laboratory -related errors, it is very important that the laboratory or facility retraces the handling of the specimens, films, and so on to determine how erroneous results were released. Appropriate policy and procedure changes should be put in place to prevent such errors from recurring.

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Role of Medical Transcription Outsourcing in Ensuring EHR Data Integrity Data integrity issues that are not addressed will create the potential for patient safety, quality of care, and compliance concerns and cascade across the healthcare system, affecting the integrity of EHRs. Organizations should educate staff on best practices for documentation with focus on the integrity of the health record. In a 2013 report, AHIMA pointed out that organizations using voice recognition without a validation step in place experience significant data quality problems and documentation errors. This can be avoided by ensuring that providers review, edit, and approve dictated information in a timely manner.

Medical transcription companies transcribe physician notes accurately for upload to EHRs. All reports are thoroughly checked before delivery. Even physicians who perform EHR data entry can do with the support of a medical transcriptionist to verify their medical reports. In fact, this is crucial for emergency department (ED) clinicians. Studies show higher incidence of EHR user-errors in busy EDs and emergency room transcription services can be a valuable option to deal with this. As EHR adoption advances, medical transcription outsourcing is still relevant to ensure the timeliness and legibility of

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