• Be mindful to time your entry, especially in those cases when it is well after the treatment. The precise time can be determined, and disputes or discrepancies over timing of the entry can be resolved.
• Take the time to familiarize yourself with the documentation system in place. The next time you sign off on an entry, remember that the document created is only as good as the information entered.
An awareness of the potential pitfalls of the EMR is the first step to making the changes that will ultimately benefit everyone involved – your patient, you, and sometimes even your attorney.
Ms. Ford is a shareholder in the law firm of Marshall, Dennehey, Warner, Coleman, & Goggin, King of Prussia, Pa., and specializes in medical malpractice litigation. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also a partner in EHR Practice Consultants, helping practices move to EHR systems. Contact him at [email protected]