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Michael J. Boranian Discusses the Legal Implications of EMR Documentation for Medical Personnel

On June 23, Michael J. Boranian, the head of the Medical Malpractice group at Montfort, Healy, McGuire & Salley, LLP, gave a presentation at a major area hospital titled “The Legal Implications of Electronic Medical Record (EMR) Documentation for MDs/Nurses/MLPs: ‘Charting’ a Better Course.” Mr. Boranian discussed practice-related issues medical staff often encounter in the documentation process, the import and impact of narrative documentation in medical malpractice claims and the jury’s perceptions of chart entries at trial. The lecture was followed by a question-and-answer session.

In his presentation, Mr. Boranian explained that jurors tend to see documentation that has been altered or contains insufficient, inaccurate or missing information as a reflection of the provider’s competence. They may focus on poor documentation rather than whether the doctor, nurse or mid-level practitioner provided quality care. He also emphasized that all interactions with patients should be documented by those responsible for making such entries and the most common errors made in documentation.

He also emphasized that communication is key in documentation, adding that poor communication was the number one root contributor to malpractice allegations and claims. What doctors, nurses and MLPs must always be aware of when recording the entries, Mr. Boranian said, is the need to follow hospital policy, record facts instead of opinions, make sure the notes follow a logical sequence with no gaps, enter the date and time for each entry and avoid the urge to “cut and paste.” When recording telephone calls, he said the information should include the name of the person who made the call, the person called, the reason for the call, the results of the call and the treatments initiated after the call.

Mr. Boranian regularly lectures before health care institutions as a public service. If you are interested in hosting a presentation, contact Mr. Boranian at (516) 747-4082 or at mboranian@mhms-law.com.

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