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.
EMRs can increase malpractice risk in documentation of clinical findings—copying and pasting previously entered information can perpetuate any prior mistakes or fail to document a changing clinical situation.1 In a study by The Doctors Company of 97 EMR-related closed claims from 2007 to 2014, 13 percent of cases involved prepopulating/copy-and-paste as a contributing factor.2 Copy-and-paste is a necessary evil to save time during documentation of daily notes, but whatever is pasted must also be edited to reflect the current situation. Too often the note makes reference to something that happened “yesterday.”
Checkboxes, particularly those that prepopulate, can be a physician’s nemesis. EMRs have been presented in court that show, through checkboxes, daily breast exams on comatose patients in the ICU, detailed daily neurological exams done by cardiologists, and a complete review of systems done by multiple treating physicians on comatose patients. Questioning in court as to how long it takes to do a review of systems and a physical examination, the patient load of the physician for that day, and how many hours the physician was at work cast doubt on the truthfulness of the testifying physician. A time analysis showed there was no way the physician could have accomplished all that was charted that day, leading to the loss of credibility of that physician in court.