Grand Canyon University Legal Implications Discussion

Legal implications are also inherent in use of EHR/EMR, especially in the use of preprogrammed “smartphrases” for repetitively entered dialogue, such as simple discharge instructions to accompany patient’s paperwork who is discharging home with new opioid pain medications. While smartphrases certainly can save time, legally all entries into the EMR/EHR are treated as discrete, intentional entries – much as if they had been written by hand in the pre-electronic days. All entering users must be careful that what they are entering truly reflects the care they provided for the patient, and that it is legally defensible should that be required.