This question is being asked increasingly often as more physicians go electronic, according to American Medical News (10/13/08). Federal Rules of Civil Procedure, approved by the US Supreme Court in December 2006, not only make electronically stored data discoverable in a trial but render physicians vulnerable to several new liabilities inherent in the detail electronic data provide.
This question is being asked increasingly often as more physicians go electronic, according to American Medical News (10/13/08). Federal Rules of Civil Procedure, approved by the US Supreme Court in December 2006, not only make electronically stored data discoverable in a trial but render physicians vulnerable to several new liabilities inherent in the detail electronic data provide.
If a nurse records information under a physician’s login and password and that information is incorrect, for example, the physician could be held liable. To avoid such a situation, you need a system where the record keeping coordinates with a record of who entered what when (the record’s metadata) to provide an accurate picture.
To protect yourself legally, the first step is to use an electronic medical record (EMR) that is certified by the Certification Commission for Healthcare Information Technology (CCHIT). The US Department of Health and Human Services contracted CCHIT in 2005 to further widespread EMR adoption, and the commission released its first set of certification criteria in 2006. But because certification criteria continue to evolve, physicians still must practice due diligence in deciding on a system. When shopping for a EMR that will hold up in court, consider how well the system meets these criteria:
[] Shows authorship by clearly indicating who entered what portion of the record
[] Deals clearly and comprehensively with changes by tracking alterations to the record as well as who made each change and when and saves the original
[] Has an audit function that supports the accuracy and validity of the record and has cross-checks
Hormone therapy safety: Study finds potential benefits for senior women
April 24th 2024A recent large-scale study challenged age-related concerns, suggesting hormone therapy may offer safety and even benefits for menopausal women aged over 65 years, aligning with The Menopause Society's 2022 Position Statement.
Read More
Hyperoxygenation use not linked to neonatal outcomes
April 23rd 2024Recent research evaluated the impact of maternal hyperoxygenation on neonatal Apgar scores, revealing no significant enhancement in outcomes among women with pathologic fetal heart rate tracing and suggesting limited efficacy of hyperoxygenation therapy in this context.
Read More
Study finds antihypertensive treatment reduces uterine fibroids risk
April 23rd 2024A recent study revealed that patients with untreated or new-onset hypertension face elevated chances of uterine fibroid diagnosis, underscoring the potential of antihypertensive therapy in mitigating this risk among midlife individuals.
Read More