Electronic medical records (EMR) are quick and effective tools for use at the hospital bedside or in clinical patient care. Interestingly, however, most health care providers are used to viewing them while providing care, but NOT in retrospect. Yet, EMRs must be viewed in retrospect to effectively evaluate all claims and litigation. These reviews of EMRs often take place months or years after the care was provided, which makes it more challenging to understand them.
A thorough review of the medical records – which we can provide – helps ensure that important facts aren’t missed!
Example Of EMR Discrepancies In A Trial Setting
Healthcare providers and nurses often aren’t familiar with how their documentation appears in the electronic medical records that are retrieved for the purpose of claims and litigation.
This inexperience can have severe consequences during trial. As an example, during a deposition, a nurse adamantly testified about the dosage of medication that she had administered to a patient, and said that the dose had never changed. Unfortunately, the nurse didn’t find all of her documentation in the printed EMR at deposition. After her deposition, it was discovered that there was documentation that she hadn’t reviewed, due to not being familiar with the printed EMR vs. the “real-time” EMR. She had to correct her testimony at trial regarding the medication dosages she had given.
Change In Testimony About An EMR Had Consequences
The defense attorney in the case hadn’t thoroughly reviewed the electronic medical record so that the nurse would be familiar with all of her own documentation prior to deposition. At trial, the nurse had to admit that she had changed the dosage of medication administered to the patient several times, and that she had misread the EMR. As a result of this change in testimony, after the trial, the jury reported that the nurse’s credibility and that of the defendant hospital was damaged – to the point that that the jury found for the plaintiff.