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EMR Documentation Issues During the COVID-19 Pandemic

EMR Documentation Issues During the COVID-19 Pandemic

Physician News posted a great article discussing EMR documentation issues during the pandemic.

As hospitals are overwhelmed with COVID-19 patients and staff are stretched to their limits, electronic medical record (EMR) documentation may suffer as a result of rushed, less detailed and error-prone entries. EMR workarounds are also expected to flourish. In the current medical malpractice climate where greater scrutiny can be placed on the EMR and audit trail over the medicine itself, it is very important to maintain an accurate chart. There are steps that can be taken now to prepare for anticipated documentation issues related to care rendered during the COVID-19 pandemic.

The most important recommendation is to be a good historian. Years from now, you will need to remind and educate counsel, judges and juries of the magnitude of this world pandemic. There are several historical factors that will help explain documentation during the COVID-19 period. Detailed hospital census data will demonstrate how it impacted your institution. You may need to compare COVID-19 period numbers to your typical census to demonstrate the difference. This information will later show that the hospital was much busier than normal, which would impact documentation practices.

EMR technical issues are usually not documented, but they need to be chronicled. If the EMR system “goes down,” or suffers widespread “glitches,” or is compromised in any way, it contributes to an EMR problem and you will need to explain it later. Best efforts should be made to detail these issues now for use later.

Hospital staffing records will also be important to show an increased reliance of locum tenens, agency nurses, “unretired” health care providers and volunteers who may not be familiar with the EMR. Included within this category are records of staff “call-offs” or sick days. In some instances, medical staff may have never used the particular EMR system prior to rendering care. Those who know how to use the system may not have the time to educate those who do not. A medical staff member’s lack of experience with an EMR system may later explain why there is little or no information in a patient’s record. It may also explain if there is a documentation error. Staffing information will be critical in explaining the EMR for care rendered in this time period.” …

Read the entire article here.


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