As was discussed in part one of this article the risks of using the technology of electronic medical records shows many things that physicians should be aware of and also how to reduce legal risks. We will continue on with this article with five other ways to reduce these risks.
6. Physicians should make sure to sign off the record or log out of the system
This practice is extremely important so that if a physician does not sign out and another physician continues under his or her log in name. This can create a problem because the bill could be submitted under the wrong physicians name. If this were to happen an insurance company can ask for a refund of payment if a medical record is submitted during an audit.
7. Understand how the system records who is accessing and writing in the record
There should be a system in place where if one is accessing the record but after a period of inactivity an automatic time-out occurs. If a physician needs to make changes or add to a record this should be done at the end of the day but there should be a time period in which the record should lock. In the case of changes being made, a new entry should be noted and it should be clearly written as an addendum to the record with the date of which this change or addition was made, the reason why the change or additional information was added and also at the end of the entry should be an electronic signature to verify the person who made the changes.
8. Print out a note from time to time to be sure your entries are in your name and record the time of the medical record entry
The past some physicians have had the habit of entering in the patients record in the era of pen and paper method, to record things that haven’t happened yet. One example could be that a physician records a date of a cesarean section but that actually hasn’t happened yet. So this would have to be entered as a notation with the actual date of when it was entered instead of in the future.
9. Make sure that only appropriate staff members have access to the records
There should be a protocol in place in case of a security breach from a staff member or other person. There should be a password that is protected when the person or persons that have authorization to log in. Having an automatic sign-out feature is also a protection in case the physician should forget to log out.
10. Protect records from inappropriate viewing by setting up screensavers and require a password for reentry
Having this feature helps if ever the laptop or computer is left in a room unattended.
Marina Hall is a Certified Medical Reimbursement Specialist (CMRS) and founder of MariAnn Medical Billing Service. To read a full “Interview with Marina Hall” visit her website at http://www.inscoding.com/aboutus.php
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