A physician from New London, New Hampshire, did not use computers to keep track of patient records. Instead, she used detailed handwritten notes and manila folders for each patient. Her small office had only a landline telephone and fax machine as subtle nods to the modern era. She used no computerized machines or diagnostic techniques, relying instead on her experience and general medical knowledge.
The doctor surrendered her license in October, after feeling pressured by authorities to do so, and her request to regain her license was denied.
Patients seek out a doctor expecting the physician to be able to diagnose and treat their ailments, making for a common law contract of sorts. When this informal agreement has been breached it can constitute as medical negligence.
Medical negligence is an action, or failure to act, by a medical professional that strays from the accepted norms of medical care. In the case of the New London doctor, a complaint regarding prescribed medication for a child was filed. When negligence leads to patient injury, or even death, the victim or their family can seek a medical malpractice claim. Keep in mind, injury to a patient is not a given in negligence cases. In order for a medical malpractice claim to have bearing, there must be both legal basis and hardship to a victim.
Outdated approach poses a problem
The doctor’s lack of technological use also posed issues for reporting controlled substance prescriptions. Every state, except for Missouri, has created a prescription drug monitoring program to combat overdoses and prescription drug abuse. The programs require prescribers to document opioids to help prevent patients from overfilling prescriptions and general misuse.
In California, doctors use the Controlled Substance Utilization Review and Evaluation System (CURES) to manage prescriptions. The program is a database for controlled substance prescriptions. Doctors, law enforcement and regulatory offices can access the database in order to track prescriptions and log information. Physicians can even use it to report the theft of their prescription pads.
Electronic records systems can be time consuming and unintuitive for users, but research proves their effectiveness. Paper records are becoming obsolete as industries transition to digital record keeping. How has your practice handled the shift?