The misuse of electronic medical records

Hospitals and other medical providers in Florida and other states are expanding their use of electronic medical records, known as EMRs. EMRs replace much of the paper medical records and can result in more accurate charting due to real-time entries by a physician or other medical practitioner.

However, EMRs can also identify negligence by medical providers and can be used by plaintiffs in malpractice lawsuits. Using the cut-and-paste function or autocorrect and templates can result in incorrect entries in a patient’s record. Ordering a wrong lab test or failing to read a lab test can be easily discovered through a review of a patient’s EMR.

Adopting the use of electronic medical records requires the proper training of staff and a period of transition from paper records. Some people may not be as comfortable with electronic systems and may make mistakes or omit entries in the EMR that would provide information on what really happened to the patient. Judges are also becoming more familiar with the use of EMRs as evidence in malpractice cases.

In some instances, hospital negligence leads directly to an injury or death to a patient. With the advent of EMRs, a hospital can be negligent in not keeping the record up to date and not providing adequate training for EMR users. A diagnosis or treatment recommendation based on an incomplete or incorrect EMR can have a serious impact on patients. A patient who has suffered a negative health outcome during a period of hospitalization may want to ask a medical malpractice attorney to review the medical records to assess whether hospital staff negligence was a contributing factor.