The Doctors Company’s analysis of claims in which the electronic health record (EHR) contributed to patient injury reveals a total of 275 claims closed from 2010 to 2019. The pace of these claims grew, from a low of seven cases in 2010 to an average of 33.5 cases per year in 2018 and 2019. EHR issues are typically contributing factors rather than the primary cause of claims, and the frequency of claims with an EHR factor continues to be low (1.2 percent of all claims closed since 2010). Still, as EHRs approach near-universal adoption, they may become a more prevalent source of risk.
A 59-year-old female patient was evaluated by an orthopedic surgeon one day after being diagnosed with a right spiral fracture of the distal fibula at an urgent care center. Her multiple comorbidities included insulin-dependent diabetes controlled with an insulin pump, diabetic neuropathy, hypothyroidism, depression, osteopenia, hypertension, rheumatoid arthritis, and chronic pain for which she was on routine narcotics. Her surgical history included repair of a calcaneal fracture and her rotator cuff.
The patient sustained the fracture as a result of a fall. The orthopedic surgeon reviewed the films taken at the urgent care center and diagnosed a right nondisplaced lateral malleolus fracture. The patient was provided a prescription for a controlled ankle motion walker. EHR documentation from this visit did not include a treatment plan, instructions for the patient to remain non-weight bearing on the right leg, or when she was to return to the office for a follow-up examination.
The patient returned for follow-up 10 days later still complaining of foot pain. Repeat x-rays were obtained and interpreted as a “lateral malleolus fracture in place.” However, EHR documentation reflected a normal foot and ankle exam and no treatment plan was documented.
Three weeks later the patient returned with pain and instability of the ankle. X-rays taken revealed a “displaced trimalleolar fracture, closed.” Again, the EHR documentation revealed a normal ankle exam and no treatment plan, despite a request being faxed from the office to the hospital to schedule the patient for surgery.
She underwent an open reduction internal fixation of the right ankle the following day and remained hospitalized for three days. The patient returned to the office on post-op day six, and x-rays showed a “loss of posterior malleolus bone position with talar shift.” She was referred to a foot and ankle specialist, but the referral was not documented in the EHR.
The patient subsequently had surgery by the foot and ankle specialist. The specialist removed all hardware, debrided the wound, and applied a large external fixator. Because there was suspicion for osteomyelitis, cultures were obtained, the wound was left open, and the patient was started on IV antibiotics. The cultures were positive for methicillin-resistant Staphylococcus aureus. After a long, complicated postoperative course that included prolonged IV antibiotic therapy, wound vacs, and subsequent hospitalizations, the patient underwent a below-the-knee amputation.
Risk Management Discussion
Exercise caution when using EHR templates and be sure to understand the system’s functionality. In this case, the EHR template was designed to auto-populate a “normal exam” for the body part chosen. As a result, the documentation for the second and third visits stated that the patient had a “normal gait. Heel walk, toe walk, knee bend, and squat without limitation. Full range of motion. Normal pulses and reflexes. Sensation intact. Pedal pulses 2+.” It was the orthopedic surgeon’s responsibility to edit the note to reflect the abnormal findings in the physical exam before completing the record.
In addition, the EHR documentation was missing a treatment plan and patient instructions for each visit. If the treatment plan and patient instructions are not part of a template, include the information as free text.
During the deposition, the plaintiff’s attorney asked the orthopedic surgeon these questions about the obviously wrong information in the EHR’s auto-populated fields:
- “So is the information in this record accurate or not?”
- “Do you bother looking at your records?”
- “If these ‘auto-populated’ fields are incorrect, can we trust anything in this record?”
- “Do you deliver the same level of care as you do in recordkeeping?”
Contemporaneous and accurate medical record documentation is vitally important in the defense of a medical malpractice claim. Familiarize yourself with the EHR templates and review any auto-populated fields for accuracy.
For assistance with EHR documentation issues in your practice, see our article “The Faintest Ink: Documentation to Defend Quality Patient Care” and our resources on EHR, Telemedicine, and E-risk or contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.