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Documentation compliance through knowledgeable staff and policy

Ida L. Landry (ida.landry@cerner.com) is Corporate Compliance Manager, Professional Services at Cerner Corporation in Portland, OR.

Have you read the news about the $1 billion lawsuit against eClinicalWorks? The lawsuit stemmed from the patient not being able to determine within his medical records when his cancer first appeared. The plaintiff stated that eClinicalWorks is at fault, because their electronic medical record (EMR) had not saved the updated data entered.[1] Although this case was terminated February 13, 2018,[2] what alarmed me was that I have seen charts very similar to this patient’s in EMR systems that are working correctly.

The fault in the defective documentation cannot be placed on the EMR system, but on that of the documenter. For example, I was talking with a friend a while back who was telling me about a state audit that she was overseeing as a liaison for the company she works for. The state auditor had printed out a provider’s patient encounters. The encounters all read the same — word for word for every visit. The auditor asked my friend if what she was seeing with the notes was a systems error or a provider error. My friend replied, “Per the metadata, it is not a systems error.” My friend could not tell me the result of that audit, but we both agreed that a lawsuit against a health system and a specific provider can easily happen because of current documentation trends. Honestly, if a lawsuit like this isn’t in the works, it will be in the future. Health systems can make a few very easy changes to help minimize their risks.

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