This article is not written to debate the pros and cons of switching to electronic medical records. It would take several pages and hours to discuss the issues with electronic medical records such as productivity, efficiency, confidentiality, patient interaction, costs savings, etc. But since it appears that electronic medical records are here to stay and will have an impact on the practice of medicine, I do think it is important to note the single most important aspect of an electronic medical record. Accuracy.
Whether the medical record is on paper or made via a computer, the importance of an accurate record cannot be emphasized enough. The patient’s medical record that you create may be viewed and relied upon by the patient and other physicians. The medical record may also be closely examined by lawyers, judges and members of a jury if you are involved in a lawsuit.
From an attorney’s point of view, an incomplete or not quite accurate medical record can be explained. In fact, often times the explanation is quite easy. But a jury does not always believe the explanation. Sometimes the jury will question the accuracy of other records if just one record is found to be inaccurate. Losing credibility with a jury can have devastating consequences.
As you implement your electronic records system and work through nuisances of that system, including where you input certain information, don’t forget to double or triple or quadruple check the information you input before moving on to the next patient. An extra few minutes now could save you countless hours in the future.