What every physician needs to knoW:

ehr Best practices

1 templates, defaults, &

copied records

Be aware:• Templates can import inaccurate information. • Some programs may be set up so that specific complaints

default to “resolved” if the physician or patient does not renew that complaint on the next visit.

EHR dRop-down mEnus and RE-populatEd data can savE timE but tHEsE fEatuREs can also lEad to mistakEs.

1 templates, defaults, &

copied records

reMeMBer:• Medical history, medications, and allergies should be

consistently updated.• Notes should be individualized for each patient encounter,

and relevant sections reviewed to avoid importing incorrect, redundant, and irrelevant information.

• Do not leave areas in templates blank. Delete those areas or mark them “not applicable.”

2 passWords

aDVICe:• avoid sharing passwords.• each staff member and physician should have his or her own

individual log in.• EHRsassociatethepersonwhoentersthatpasswordastheauthoroftheentryinthepatient’smedicalrecord.

• Staff members should not have access to the physicians’ level of security.• Staffshouldhavetheirownpasswordsandlevelofsecurityclearancebasedontheirjobfunctions.

completing & locking notes

• Information is likely to be more accurate if completed immediately after the visit, and is more secure if electronically signed and locked.

• Physicians and staff are encouraged to use a thorough test tracking method instead of leaving notes “open” until results are received.• Asmalldelayinsign-offmaybeacceptableiftestresultsarereceivedpromptly(onetotwodays).

3aftER a patiEnt visits, tHE EncountER REcoRds sHould bE

ElEctRonically signEd and “lockEd” as quickly as possiblE.

tracking & signing test

results

• when referring patients to a specialist or an outside source for lab or diagnostic tests, a tracking system is critical to ensure the patient is seen and the results are received.• MostEHRsystemshaveelectronicordertrackingforreferralsanddiagnostictests.

• Make sure the report review format clearly states the date the results were reviewed.

4

“to do” lists

reMeMBer:• If you use electronic tasks, messages, or “to-do” lists, review

items on the list consistently and promptly.• regularly reviewing diagnostic results and documenting your

review can help to defend against allegations of delay in diagnosis or failure to follow up.

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addendum process

reMeMBer:• Include the reason for the lateness of the entry, date, and name

of the person making the late entry.• Late entries that are not clearly identified could be viewed as an

alteration to the medical record. • Thiscouldcompromisethephysician’scredibilityandthedefenseofaclaim.

6clEaRly idEntify latE EntRiEs madE in tHE EHR.

documEnt tHat a scRibE was usEd to makE EntRiEs into tHE EHR.

use of scribes

• a scribe can be an advanced practice provider (aPP), nurse, or other staff member the physician allows to document services in the medical record.

• Documentation of scribed services must clearly indicate who performed the service, who recorded the service, and the qualifications of each person (i.e., professional degree, medical title).• Documentationshouldbesignedanddatedbyboththephysician/APPandscribe.

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ehr policies & procedures

• Federal privacy and security rules require all practices to develop protocols to protect the integrity and security of their eHr (referred to collectively as electronic protected health information or PHI).

• Policies should be signed by the physician and include implementation dates.

• Staff members should sign and date their acknowledgment of review and understanding of the policies and procedures.

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protection for a neW era of

medicineabout tmlt:with more than 17,500 physicians in its care, Texas Medical Liability Trust (TMLT) provides malpractice insurance and related products to physicians. Our purpose is to make a positive impact on the quality of health care for patients by educating, protecting, and defending physicians. www.tmlt.org

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