Electronic Health Records (EHR) and Electronic Medical Records (EMR) provide a wealth of information about a client’s medical history and treatment. They are an invaluable tool when analyzing whether a client has a viable medical malpractice claim, and if there is a claim, they can be used to show a breach of a standard of case and prove liability.
EMR
An Electronic Medical Record is a digital version of a patient’s chart. It contains all details “medical” such as diagnosis and treatment history. This digital record typically stays with the provider’s office and is not shared with any other practice. If a patient changes from one doctor or hospital to another, his or her EMR likely will not be transferred. Instead, the patient’s records might have to be printed, scanned, and e-mailed or mailed in order to be shared. Benefits of an EMR include:
- Monitoring and identifying which patient is due for treatments, therapy, or vaccines.
- Tracking internal performance metrics.
- Improving the care delivery model.
- Its digital nature allows easy storage & accessibility preventing errors, loss & tampering of sensitive information.
EHR
An Electronic Health Record contains the patient’s records from multiple doctors or hospitals and provides a more ample, long-term view of a patient’s health. It consists of a patient’s demographics, test results, present illness conditions, clinical history, mental health data, current and present medications. Benefits of an EHR include:
- Allows sharing of important health information nationwide (or worldwide) in a protected manner.
- Aids important decision-making processes in terms of a patient’s health.
- Acts as a repository for all test results such as lab tests, x-rays, radiology results, etc.
- Improves patient engagement by allowing patients to access and comprehend their health metrics.
How to use an EMR & EHR efficiently in a medical malpractice case?
When compared to paper records, an Electronic Health Record or Electronic Medical Record is an additional information administration tool that helps attorneys efficiently organize, understand, and analyze a client’s health information and data. EMR or EHR are searchable using OCR technology, which allows for the quick and efficient isolation of a client’s medical history, diagnosis, medications, and treatment history. Once the relevant timeframe and information is isolated, it can be reviewed by the attorney or sent to a medical expert or legal nurse consultant to determine if appropriate clinical decisions were made and whether the standard of case was breached.
In addition, there are times when an audit trail of the EMR or EHR is, in and of itself, evidence that can be utilized in a medical malpractice case. An audit trail, which shows who accessed an EMR or EHR and what operations were performed, will capture when information was viewed, added, deleted, or modified. That information may be the key to providing liability and prevailing in a case.
AcroDocz provides medical records retrieval, medical record chronologies, and demand package preparation services to law firms nationwide. To learn more about our services, please call us at (786) 633-3100 or email us at info@acrodocz.com.
