As EHR use increases rapidly, TMLT is focused on helping physicians reduce their medical liability risks as they navigate the world of electronic documentation. Please consider the following to help reduce risk related to EHR systems.

1. What every physician
needs to know:
EHR BEST PRACTICES

2. 1 templates,
defaults, &
copied records
Be aware:
• Templates can import inaccurate information.
• Some programs may be set up so that specific complaints
default to “resolved” if the physician or patient does not renew
that complaint on the next visit.
EHR drop-down menus and re-populated data can save
time but these features can also lead to mistakes.

3. 1 templates,
defaults, &
copied records
REMEMBER:
• Medical history, medications, and allergies should be
consistently updated.
• Notes should be individualized for each patient encounter,
and relevant sections reviewed to avoid importing incorrect,
redundant, and irrelevant information.
• Do not leave areas in templates blank. Delete those areas or
mark them “not applicable.”

4. 2 PASSWORDS
ADVICE:
• Avoid sharing passwords.
• Each staff member and physician should have his or her own
individual log in.
• EHRs associate the person who enters that password as the
author of the entry in the patient’s medical record.
• Staff members should not have access to the physicians’ level of
security.
• Staff should have their own passwords and level of security
clearance based on their job functions.

5. completing &
locking notes
• Information is likely to be more accurate if completed immediately after
the visit, and is more secure if electronically signed and locked.
• Physicians and staff are encouraged to use a thorough test tracking
method instead of leaving notes “open” until results are received.
• A small delay in sign-off may be acceptable if test results are received
promptly (one to two days).
3After a patient visits, the encounter records should be
electronically signed and “locked” as quickly as possible.

6. tracking &
signing test
results
• When referring patients to a specialist or an outside source for lab or
diagnostic tests, a tracking system is critical to ensure the patient is
seen and the results are received.
• Most EHR systems have electronic order tracking for referrals and
diagnostic tests.
• Make sure the report review format clearly states the date the results
were reviewed.
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7. “to do” lists
REMEMBER:
• If you use electronic tasks, messages, or “to-do” lists, review
items on the list consistently and promptly.
• Regularly reviewing diagnostic results and documenting your
review can help to defend against allegations of delay in
diagnosis or failure to follow up.
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8. addendum
process
REMEMBER:
• Include the reason for the lateness of the entry, date, and name
of the person making the late entry.
• Late entries that are not clearly identified could be viewed as an
alteration to the medical record.
• This could compromise the physician’s credibility and the
defense of a claim.
6 CLEARLY IDENTIFY LATE ENTRIES MADE IN THE EHR.

9. Document that a scribe was used to make entries into
the EHR.
use of scribes
• A scribe can be an advanced practice provider (APP), nurse, or other
staff member the physician allows to document services in the medical
record.
• Documentation of scribed services must clearly indicate who performed
the service, who recorded the service, and the qualifications of each
person (i.e., professional degree, medical title).
• Documentation should be signed and dated by both the
physician/APP and scribe.
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10. ehr policies &
procedures
• Federal privacy and security rules require all practices to develop
protocols to protect the integrity and security of their EHR
(referred to collectively as electronic protected health information
or PHI).
• Policies should be signed by the physician and include
implementation dates.
• Staff members should sign and date their acknowledgment of
review and understanding of the policies and procedures.
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11. protection for
a new era of
medicine
about tmlt:
With more than 17,500 physicians in its care, Texas Medical Liability Trust (TMLT)
provides malpractice insurance and related products to physicians. Our purpose is to
make a positive impact on the quality of health care for patients by educating, protecting,
and defending physicians. www.tmlt.org
Find us on:
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