What exactly defines portions of the “medical record” in the electronic era?
(a) The patient's family history
(b) The physical examination
(c) The Medication Administration Record (MAR)
(d) Patient chest xrays
(e) Patient billing information
(f) Discharge summaries
(g) Operative reports
(h) Physician “In Basket” Electronic Messages within Electronic Medical Record (EMR) software (specifically defined as NOT "e-mail")
(i) Physician office e-mail messages outside of the medical record software.
Sadly, I learned today that for physicians who use an EMR, “all of the above” is the right answer. No longer can physician colleagues communicate electronically about a patient without fear that their electronic communications are “discoverable” in the eyes of the law. It seems physicians who have adopted the EMR have tactitly agreed that electronic messages are part of every patient's medical record.
I never learned that in medical school.
Back then, we just had the chart in our hands. We used to be able to go down to a medical record room we'd put in a request for a nice lady to "pull the chart." She'd return with a definable entity in her hands. Certainly, e-mail threads were not part of that record.
But in the electronic era, that no longer applies.
Certainly, the potential liabilities in e-mailing patients has been well-recognized. But messaging colleagues about your concerns or doubts about a specific treatment plan for a given patient? It seems that it's all potentially fair game for legally-minded interested third parties.
So if you're thinking about acquiring an EMR, beware. Being forewarned, you're now forearmed.