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risk management representatives visited practices where all clinical staff mem- bers share the physician’s password.) Not all employees need access to


the EMR. Some practices limit access to those in direct patient care. Others may allow nonclinical staff to only view (and not enter or edit) information in the EMR. When an employee with ac- cess leaves the practice, delete his or her password immediately. Make sure patient encounter records


are electronically signed and “locked.” The information in the EMR is likely to be more accurate if entered immediately after the visit or within 48 hours. If your practice uses dictation systems in conjunction with the EMR, include the date of dictation or date of transcrip- tion. The author of each entry must take specific action to verify that the entry is his or hers and that it is accurate. Review notes generated or supple- mented by dictation into a voice recog- nition system before closing the note. Once a patient encounter entry is com- pleted, the author should sign it and lock it in the system. Because not all EMRs are set up to perform this task, training may be required.


If information needs to be added or comments made after the entry is locked, clearly identify the new entry as an ad- dendum with current date, reference to the date being amended, electronic signature, and reason for the late entry. Anyone who makes changes and adden- dums should ensure that they are clearly marked as such. Unclear, after-the-fact entries may be viewed as alterations to the medical record, which can compro- mise the defense of litigation. Clarify the provider signature of all notes or entries. Another potential weak- ness identified in some systems may be a lack of clarity regarding when the phy- sician electronically signed a note. The record should clearly indicate the date of electronic signature. This demonstrates to an outside reviewer that the physician promptly signed the record at the end of the visit. While a physician signature could most likely be verified somewhere in the system, ideally the note itself should show the electronic signature of the physician.


When an employee with


access leaves the practice, delete his or her password immediately.


Additionally, some programs do not


allow each clinical staff member making entries to authenticate the entry with an electronic signature. It is recommended that each staff member electronically sign when possible. If electronic signa- ture or automatic generation of the iden- tity of the person entering information is not possible, staff may wish to type their name or initials in all entries in the med- ical record. If none of these are feasible, practices should check into whether they can generate an electronic “audit trail” to trace staff entries. Avoid electronic sign-off without


reviewing orders, electronic tasks, or emails. In conjunction with the previ- ous recommendation, signing an order affirms that it is correct. Auto-authen- tication techniques that do not require the author to review and sign the entry should be avoided. Do not “universally” click off on a series of orders, tasks, diag- nostic results, or emails without review- ing them. Avoid using templates that allow the importing of old or inaccurate informa- tion. Most EMRs have been designed with templates for patient encounters. While these drop-down menus save time, many physicians are not aware that some EMRs repopulate the same data in the templates for each subsequent visit. For example, a physician sees a pa- tient who has conjunctivitis and notes


this in the “review of systems” section. At the next visit, if the physician does not edit the “review of systems” section, the conjunctivitis is again noted. The system will continue picking up this in- formation from the templates, giving the impression that the treatment plan is not working or that the physician is not edit- ing the record. Conversely, some programs may be set up so that specific complaints default to “resolved” if the physician or the pa- tient does not renew that complaint on the next visit. Individualize the notes of each patient encounter, and review rel- evant sections to avoid importing infor- mation that is incorrect, redundant, and irrelevant.


Enable the EMR’s tracking mecha- nisms. Most software programs include a tracking system to help ensure that patients have completed recommended tests or consultant referrals. However, risk management representatives visited many practices that do not use these sys- tems or have not discovered them. These tracking systems can minimize exposure to allegations of failure to diagnose and can lead to better patient care. Specifi- cally, they can provide a way to:


• Verify that the patient keeps the ap- pointment or completes the test;


• Confirm receipt of the report; • Prompt a call to the consultant, im-


April 2013 TEXAS MEDICINE 15


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