Atlanta Legal Nurse Consultant Discusses Legal Pitfalls of Electronic Medical Records With Atlanta Nurses

Atlanta, Georgia – Atlanta legal nurse consultant Liz Buddenhagen, registered nurse and certified legal nurse consultant, presented at Rockdale Medical Center in Conyers, Georgia on January 3 and 7, 2011, regarding legal issues with electronic medical record (EMR) nursing documentation.

About the Legal Workshop:

Attorneys Dan Huff and Evan Cline, of defense law firm Huff, Powell & Bailey, started off the four hour workshop with a mock trial.

The Atlanta legal nurse began her two hour presentation with basic elements of the legal process as involved with medical negligence cases. Buddenhagen went over standards of care, standards of nursing practice, legal elements of a medical malpractice case, and a simplified timeline of a medical negligence legal case.

Buddenhagen followed with discussion of nursing documentation both handwritten, and electronic. Clinical nurses are intimately familiar with the time constraints of their jobs being the number one obstacle to producing thorough documentation. “The documentation is tremendously important in most lawsuits,” said Buddenhagen.

The many purposes of medical documentation such as interdisciplinary coordination of care, evidence of adherence to quality medical/nursing care, research, and discharge planning data were highlighted. Documentation nursing standards were reviewed and effective documentation – FACT – factual, accurate, complete and timely was delineated.

Buddenhagen finished the workshop with discussion specific to electronic documentation noting the advantages, and disadvantages of the EMR. Everyone is in agreement that the electronic record is legible thus eliminating the age old complaints of no one being able to read some doctors, and nurses handwriting. However, some complaints regarding the electronic record are that sometimes there is not enough information recorded by healthcare providers, some charting may be incorrectly credited to the wrong healthcare provider should the prior provider not log off appropriately, and the grossly inappropriate use of text language instead of English language in the medical record.

Wrap Up:

As the nation transitions to electronic health records, the pitfalls of the newer systems can be eradicated with continued effort to improve the systems. Buddenhagen encouraged the nurses to continually update their managers, and informatics staff of any needed improvements to their electronic documentation systems to ultimately make the electronic health record work as ideally as possible.

About Liz Buddenhagen:

The Atlanta legal nurse consultant is a thirty year hospital charge nurse with five years of experience assisting Atlanta attorneys with the medical aspects of their legal cases. Buddenhagen is principal at Buddenhagen & Associates. Visit www.Legal-Nurse-Consultant-LNC.com for more information, email at Liz@BuddenhagenLNC.com or call 770-725-2997.

Contact Information

Liz Buddenhagen, RN, CLNC

Principal

Buddenhagen & Associates

Contact via E-mail