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Charting by computer without an EHR

Article

Until I get an EHR, I've been typing my care notes into a Microsoft Word template. Then I print them out, sign them, and store them in the patient's chart. I save the electronic copy in read-only format on a network server that's password protected. Do you see any weaknesses in this system that, in a malpractice trial, might give a plaintiffs' attorney the opportunity to suggest that I could have altered records?

Until I get an EHR, I've been typing my care notes into a Microsoft Word template. Then I print them out, sign them, and store them in the patient's chart. I save the electronic copy in read-only format on a network server that's password protected. Do you see any weaknesses in this system that, in a malpractice trial, might give a plaintiffs' attorney the opportunity to suggest that I could have altered records?

No. Since you store printed and signed copies of your notes in patients' charts, those documents will be no more assailable than any other chart record. As long as you can demonstrate that you don't alter records once they've been signed-but instead routinely make dated and signed addendums to record additions and changes-your testimony will be credible.

Send your practice management questions to: PMQA Editor, Medical Economics, 123 Tice Blvd., Suite 300,Woodcliff Lake, NJ 07677-7664, or send an e-mail to mepractice@advanstar.com (please include your regular postal address).

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Jennifer N. Lee, MD, FAAFP
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health