Communication and documentation considerations for electronic health records

Abstract

Electronic health records (EHRs) are here to stay, and their use is expected to grow significantly in the future. It is incumbent on risk managers to ensure their use does not inhibit good provider-to-patient communication. Providing education and strategies on how to make the patient encounter meaningful while the provider uses an EHR may increase patient satisfaction and may contribute to a favorable professional liability loss experience. Risk managers also need to have an understanding of the capabilities of each specific EHR system in the facility, the implications of the ability to cut-and-paste information from one provider entry to another, and knowledge of how to control the risk that comes with both copying forward and delayed EHR documentation.