Computerized medical records are here to stay. Not perfect, but better than handwritten records. This method of recording information about a patient offers many advantages but also some significant disadvantages.
Computerized medical records have drawbacks that affect the legal nurse consultant’s ability to analyze medical records.
Drawbacks of computerized medical records
- Electronic health records can spread information about controversies concerning a patient. Patients may have difficulty finding physicians willing to treat them after a conflict has occurred with a healthcare provider. A threat of, or an actual, malpractice suit, a patient who is labeled as difficult or non-compliant, or a conflict with a nurse or physician that is memorialized in medical records may dissuade other providers from assuming care of the patient.
- A common complaint about computerized medical records is that some of the individuality of charting is lost. Since the same stock phrases are used over and over, charting on patients can end up sounding alike. While this is also a potential pattern in manual documentation, it is more clearly evident with computerized documentation.
- Although software programs usually allow free text entry (narrative notes), many nurses either don’t know how to type or don’t take the time to create free text entries. This can create frustration for the attorney trying to obtain a clear picture of the patient’s status.
- Free text entries are often brief and may not adequately describe an incident or series of events leading up to an emergency. This greatly increases the difficulty in analyzing liability in medical malpractice cases.
- Computers may confuse the ability to determine what actually happened before an incident.
While these deterrents have always existed, the ability to find this information about a prospective patient is made much easier when electronic health records can be accessed by other providers.
In Jason Peterson and Alicia Peterson, Individually and as Next of Friends of Alyssa Peters, a Minor vs Mckenna Memorial Hospital, Inc. and Dr. Zachary Window, confusion surrounded the dosage of Pitocin given to a laboring mother. This 2003 Texas case involved Alicia Peterson, who was in labor. Her physician ordered Pitocin to augment labor.
The records indicate the Pitocin was doubled and tripled by the nurse in violation of the doctor’s orders and that the nurse exceeded the maximum dosage ordered by the physician. The nurse denied violating the doctor’s orders and testified she made a computer entry error. She testified she was trying to record an increase of the epidural, not an increase of the Pitocin.
The child was born with a broken clavicle, a broken ulna, and Erb’s palsy. The verdict was $35,000. The hospital and physician settled before trial. The award was reduced to $15,000 by credit.
Computerized medical records offer both advantages and disadvantages. What do you think – are you for them or against them? What do you see as issues?
From Pat Iyer and Sharon Koob, Nursing Documentation, in Pat Iyer, Barbara Levin, Kathleen Ashton and Victoria Powell, Nursing Malpractice, Fourth Edition.