Computerized medical records and litigation

Attorneys and legal nurse consultants spend much time poring over computerized medical records and litigation intensifies the need to understand these records.

There is a strong trend to computerization of medical records. This method of recording information about a patient offers many advantages in litigation.

Computerization of documentation provides some benefits for those involved in litigation. When asking a facility for a policy/procedure saved in an electronic form, the attorney may need to identify the key words of the document. For example, the facility’s employee might be able to insert the word “falls” into a search box to retrieve all relevant electronic policies.

Many facilities are also putting their policy and procedure manual “on line”. The unit’s policies and procedures are thus readily available instead of being contained in huge three-ring binders. Thus it becomes easier to use the policies and procedures to follow the standard of care and to document accordingly.

A work list of activities that need to be completed for a patient can be created in some electronic medical records systems. For example, the treatments and medications that are due to be administered over the course of a shift may be printed out for a nurse.

Advantages of Computerized Medical Records and Litigation

• One of the most obvious benefits of computerized medical records is the creation of legible records. Computer printed records are completely legible, therefore eliminating the confusion caused by guessing at the meaning of handwritten words.
• The identities of the healthcare providers are easy to determine, as each entry is followed by either initials or a full name and status MD, RN, LPN and so on). If the entry is followed by initials, somewhere else in the document the person’s full name will appear.
• The programs which incorporate the facility’s standards of care prompt the healthcare provider to enter the essential information. For example, an admission assessment would include information that would identify the patient’s risk for skin breakdown or for a fall. This type of prompting focuses the nurse’s attention on key clinical issues and reminds the nurse to collect and enter the data that would fulfill the standard of care.

Computerized medical records and litigation make some aspects of the legal process easier, but there are also some significant problems associated with their use.

This material comes from Nursing Malpractice, Fourth Edition.