Advancements in the process of documentation in the medical field aim to improve accuracy and provide a reliable reference for patients and professionals to optimize healthcare and minimize malpractice. If not maintained effectively, however, complications can arise. For example, electronic medical records provide such an opportunity for improvement, but education, skill and effort are required on the part of the healthcare provider for a successful final product.

The failure to keep EMRs sufficiently maintained has been responsible for a number of malpractice cases in which poor documentation was involved, says one source. The damages accumulated to millions of dollars paid out to patients. EMRs have become a specific concern in the courtroom, particularly in regards to the provider's responsibility to effectively document cases.

In past cases with EMRs as a primary focus, judges have expressed issues with the copy and paste technique, unclear notes or the overuse of the autocomplete function. By improperly maintaining EMRs, the physician who provided and adequate care may be vulnerable to possible medical and legal complexities. For example, the absence of documentation of necessary information regarding the evaluation of a particular test that may have played a part in a misdiagnosis could result in a doctor being found negligent even if the proper steps had actually been taken. With some courts finding doubt in the value of EMRs, it is recommended that healthcare providers prioritize the documenting process for their own protection as well as the patient's to minimize the impression of substandard hospital care.

When a medical mistake results in patient harm, a lawyer may be able to review the relevant medical documents for indications of malpractice. If found negligent, the healthcare provider may be responsible for compensating the victim's loss.


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