Medical Records and Documentation

MAY 22, 2017
MACRA Is a Marathon, Not a Sprint: How to Get Started Now
Physicians and practice managers may feel as if they’re being left at the starting line, there is still time to get in the MACRA race. This article has tips no matter where you are in the process.

JAN 05, 2017
The Faintest Ink
Carol Murray, RHIA, CPHRM, Patient Safety/Risk Manager II.
Complete and timely documentation of the medical record not only enhances patient care, but it also serves to strengthen your credibility if you are called upon to defend that care.

OCT 25, 2016
Optimize the EHR: Better Workflow Means Better Work-Life Balance
There are tools that can streamline patient care and payment workflows in the electronic health record (EHR). By dedicating time and effort up front to optimize the EHR, physicians can get relief from administrative tasks, reduce duplicate entry of data, and save time by not having to search for records in multiple places.

SEP 23, 2016
The Perils of Printing an Electronic Health Record
David B. Troxel, MD
A design flaw in an electronic health record system led to a malpractice claim against our insured cardiologist.
From The Doctor’s Advocate

MAY 06, 2016
Shared Responsibility for Preventing Malpractice Suits–Patient Interactions
Susan Shepard, MSN, RN, Senior Director, Patient Safety and Risk Management Education, and Carol Murray, RHIA, CPHRM, Patient Safety Risk Manager II.
The basic emotions leading to any medical liability action are surprise, disappointment, and anger.

APR 04, 2016
Frequently Asked Questions: Medical Records Issues
Susan Shepard, MSN, RN, and Richard F. Cahill, JD
Our experts answer frequently asked questions about medical records, such as length of retention, how to destroy hard copy paper records, and making backups of electronic health records.

FEB 23, 2016
Smile! The Doctor Is on Camera: The Pros and Cons of Recording Office Visits and Procedures
As smartphones have become ubiquitous—giving patients a video and audio recorder that’s always at hand—the question of whether or not these devices should be allowed in the clinic or hospital setting is becoming increasingly more common. The issue of allowing patients to record their appointments requires balancing potential privacy and liability risks with the potential benefits of improved patient recollection of instructions and treatment adherence.

JAN 06, 2016
Requests to Amend a Medical Record
Susan L. Marr, MSA, CPHRM
When a patient requests an amendment to the medical record, the record should contain both the patient's request and the physician's response.

OCT 01, 2015
The Defensible Medical Record
Mark Gorney, MD, FACS (deceased), Governor Emeritus; Richard Cahill, Esq., Vice President and Associate General Counsel; and Susan Shepard, MSN, RN, Director, Patient Safety and Risk Management Education.
Most errors of medical judgment can be successfully defended with a complete and unaltered medical record.

JUN 01, 2015
Frequently Asked Questions: General Topics
Cynthia Morrison, RN, CPHRM
Our experts answer questions about topics such as dictation, storage of medical records, and stolen prescription pads.

APR 06, 2015
Accurate Medical Records: Your Primary Line of Defense
Mark Gorney, MD, FACS, Richard Cahill, JD, and Susan Shepard, MSN, RN
It is critical for every physician to maintain meticulous records, because every medical malpractice suit can be won or lost based on the quality and content of the medical record.

MAR 24, 2015
Up in the Cloud: Is It Safe to Store PHI on Remote Servers?
Cloud storage is a convenient and cost-effective solution for medical practices and facilities, but precautions must be taken to ensure stored patient data is secure. This article has tips for choosing a cloud service provider.

FEB 05, 2015
Make Sure Your Medical Records Are Legible
Illegible patient records pose a risk to patient care, drain healthcare resources, jeopardize optimal reimbursement, and carry potential legal ramifications.

JAN 12, 2015
Electronic Medical Records May Cast Physicians in Unfavorable Light During Lawsuits
While the electronic medical record (EMR) has advantages, it also has introduced liability risks. EMRs can lead to lawsuits or result in a weak defense by casting the physician in an unfavorable light.

DEC 12, 2014
Curbside Consultations
Susan Shepard, MSN, RN
Physicians should be aware of the potential liability of informal "curbside" consultations, especially if expectations between the physicians are not clearly communicated.

NOV 01, 2014
Bad Outcomes: From Surprise and Disappointment to Anger and a Lawsuit
Mark Gorney, MD, FACS, and Richard Cahill, JD
Anger is by far the most common factor that moves a patient to file a malpractice claim.

AUG 01, 2014
Medical Records Disposition When Closing a Practice
Susan Shepard, MSN, RN
The physician or physician group practice is responsible for making appropriate arrangements for the disposition of medical records when a practice closes.

JUN 19, 2014
Medical Record Retention
Richard Cahill, JD.
A number of variables affect the length of time a physician should keep a medical record, such as state and federal laws, medical board and association policies, and the type of record (for example, an adult patient versus a pediatric patient record).

OCT 29, 2013
Malpractice Case Shows Risk from Physician Not Dating and Initialing Reports
Physicians must be certain that there is a process in place to ensure that no imaging, laboratory, or consultant's report is ever filed unless it has been dated and initialed by the physician as proof that it was reviewed.

OCT 25, 2013
Interactive Guide for Hospitals: Ancillary Care Areas: Medical Records
Medical records can create areas of potential malpractice exposure; this guide can help uncover risks.

MAR 28, 2012
Rx for Diagnosis
Focus on documentation and communication to help avoid breakdowns in the diagnostic process.

OCT 01, 2011
Signing Off and Signing Out: Lost in Translation
Ann S. Lofsky, MD, and Susan Shepard, MSN, RN
Whether signing out to a colleague for the weekend or permanently closing a practice, handing off responsibility for patient care can create liability risks for the physician.

JAN 01, 2005
Upgrading the Chart: A Dangerous Practice
Mark Gorney, MD, FACS
Alterations of medical records can make otherwise perfectly defensible cases almost impossible to defend.

SEP 01, 1999
Obtaining Informed Consent in a Teaching Situation
Mark Gorney, MD, FACS
It is important to inform patients when a resident physician will perform all or part of a procedure.

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