Medical Legal Consulting News, May 2014
IN THIS ISSUE:
- MLCS “Believe It or Not”: Electronic Medical Records
- Vocabulary Quiz: Medical Record Documentation
Welcome to the spring edition of MLCS’ E news!
We hope you are well and enjoying the respite of spring. Spring is a time for growth. At MLCS, we’re enjoying our own “spring” training while awaiting some technology upgrades and a new website.
Continuing with our Believe It or Not series, in this issue we’ll share some of our electronic medical record (EMR) findings. We would like to say that these challenges with EMR are rare, but unfortunately, they seem to be the rule. As is the case with any new technology, there are both upsides and downsides. The good news is, MLCS is adept at finding the truth in medical records, no matter their format.
This issue’s vocabulary quiz is on medical records terminology; have fun testing your knowledge, and seeing how you fare!
Linda Luedtke, RN, MSN
President, Director of Consulting Services
MLCS “Believe It or Not”: Electronic Medical Records
Electronic medical records (EMR) are generally thought to increase efficiency by making the documentation process easier, faster, more legible and more extensive—even automatic. But this has not reduced the complexity of medical record review for injury cases.
MLCS has encountered EMR significantly increasing the volume of records that may be generated for a single day of treatment. For example, in the “old days”, nursing records for one day in the ICU were often limited to six pages. We have seen this grow at some facilities to over 200 pages of EMR. It is not uncommon for a brief hospital stay to generate several hundred pages of records. In most situations, we continue to recommend at least a cursory review of all records as there may be relevant information hidden like a needle in a haystack.
The organization of EMR can make understanding the chronology of events a challenge for even medical professionals. Records do not necessarily read from most recent to oldest or the reverse. We have encountered EMR records printed or digitally saved in a seemingly random organization of dates. We have seen more than ten years of physician orders for medications and diagnostics documented out of chronological order on a single page.
Why would it be this way? We have cracked the code in some situations—the orders may be sorted by the ordering department at the medical center, the type of medication or diagnostics, and/or the ordering physician. We have also learned this information cannot be assumed to be extraneous; rather, this type of listing may glean information regarding pre-accident use of anti-inflammatory, narcotic and psychotropic medication and be the only reference to some treating physicians.
In our extensive work with electronic medical records, we’ve also found that the auto-population properties of some electronic medical records systems can lead to incorrect information in the record. A single dictation error or misspeak on a history may be repeated in records from multiple departments or specialties at the same facility. The repetition of the history makes it appear to be fact. Many health professionals utilize a “copy and paste” approach to histories; this too can contribute to erroneous information being continued.
The auto-population or “prompt” feature of history and physical records may result in a particular finding being documented as “present” and “not present” within the same office note. In such cases, the legal nurse consultant includes the conflicting data in her chronology of records, but when completing the analysis would consider the documentation with discrepancy in context with the whole record, identifying the gray areas.
The auto-population features of an EMR system become particularly noticeable when the record is copied. Some EMR systems will fill in the empty blanks at that point. History, vital signs, and medications lists completed at a later visit may be dumped into earlier ones that did not have such data originally. In such circumstances, the legal nurse consultant will have to be alert as to the date a particular line of information has been added and/or to the provider making the entry.
As you can see, EMR has not simplified the medical record review process necessary to evaluate personal injury claims and, in many respects, has brought with it some additional challenges. But electronic records are here to stay, and the good news is MLCS is adept at handling them and their potential problems—whether it’s condensing copious records, highlighting potential errors, excavating hidden details or navigating various organizational structures. Our experience not only in reviewing medical records, but in the clinical situations such records are generated in, helps us to locate and recognize allegation-relevant data in any format of medical record.
Vocabulary Quiz: Medical records terminology
Are you up-to-date with the most current terminology used in medical records?