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ELECTRONIC
MEDICAL RECORDS
Documenting Patient Care
in EhRs
By Joey Berlin, Reporter, Texas Medicine
Electronic health records (EHRs) and the requirements for main- TMB proposed the rule changes to address three problems the
taining them present a seemingly endless array of complications for board identified with EHRs:
physicians — with penalties potentially awaiting doctors who don’t • Records for different patients that looked too similar to one an-
follow the Texas Medical Board’s (TMB’s) recordkeeping rules.
other;
Revisions to those rules, which TMB adopted in the spring, at- • Relevant electronic communications not being properly reflected
tempt to underscore the importance of accurate information in the
data-saturated EHR system and make doctors’ electronic reporting in the medical record; and
requirements clearer. • Pre-populated fields in EHRs implying tests had been performed
that, in fact, had not.
14 San Antonio Medicine • August 2016
