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Patient Safety
and Risk Resources

Medical Records and Documentation Resources

  • 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.
  • SEP 09, 2013
    The Faintest Ink
    Carol Murray, RHIA, CPHRM
    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.
  • 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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