Proper EHR documentation Below are several of the many steps you can take to ensure you ’ re documenting patient assessments and other information correctly in the EHR :
Follow basic documentation principles . Whether you ’ re documenting on paper or in an EHR , the same basic principles apply . Document promptly , accurately , and without bias . Don ’ t interject opinions about patients or providers . When making a correction to previously recorded information , include the reason for the change . Remember that the EHR provides a date and time for each entry , providing a clear documentation trail .
Adhere to policies , procedures , regulations , and guidelines . In the event of a legal action , one of the first steps an attorney will take is to determine if you followed your organization ’ s policies and procedures related to nursing assessments and documentation , as well as any relevant local , state , or federal standards and guidelines from professional associations .
Copy and paste cautiously . The copy and paste feature in EHRs can be a time saver , but errors , including errors of omission , can easily occur . For example , you copy your note for one patient with a myocardial infarction ( MI ) into another MI patient ’ s record but forget to add that you notified the provider of the new S4 you heard on auscultation . If the patient later experiences severe heart failure , you will have no evidence that you notified the provider . Another problem with copy and paste is that errors can rapidly spread as others pick up the same erroneous information . For instance , a nurse copies an assessment for a patient with pneumonia several times , forgetting to update the temperature , which has returned the normal . The patient ’ s physician reads the note , thinks the patient isn ’ t responding to treatment , and changes the antibiotic . Subsequently , the patient experiences a significant adverse event from the new antibiotic , which leads to legal action against the hospital , the physician , and the nurse .
A report from the Partnership for Health IT Patient Safety recommends that providers “ act with volition ,” thinking about what is appropriate for copying and pasting and reviewing notes carefully . Ideally , the EHR should have a mechanism for easy identification of material that has been copied and pasted ( for example , a different color text ), so that providers are reminded to carefully review .
Beware of autofill and templates . Like copy and paste , the autofill feature can save time by avoiding repetitive entries , but you need to verify that the information automatically filled in is correct . Similarly , templates for regularly occurring events such as the first postoperative visit after a total knee arthroplasty can help save time and ensure needed information is collected , but you still need to be aware of individual patient needs and assessment findings .
Use notes appropriately . Sometimes what you need to document as an assessment finding isn ’ t in a checklist or pull-down menu . Don ’ t choose the “ next best ” option ; doing so can lead to miscommunication and clinical and billing errors . For example , if you select “ pressure injury ” because “ skin tear ” isn ’ t available , legal action would be based on the more serious injury . A better approach is to add a note to the patient ’ s record . Be sure your note provides vital information in a succinct matter to avoid “ note bloat ” ( which is also a side effect of inappropriate copy and paste ).
Protect patient privacy . Do not share your passwords and change them regularly , according to your organization ’ s policy . In addition , don ’ t enter information in view of other patients .
Don ’ t ignore alerts . Alerts are there to help you make better decisions when it comes to patient care . For example , when you enter your assessment data , you may receive an alert that a patient could be at risk for sepsis . Your prompt action could save the patient ’ s life .
Complete an effective assessment . You won ’ t have the information you need for the EHR unless you perform a quality patient assessment . Don ’ t simply consider what a computer checklist tells you to include . Use your critical thinking skills to match the assessment to the patient .
Document changes in the patient ’ s condition . Remember to enter changes to the patient ’ s status into the EHR and include if and when you notified the provider of the change .
A partnership Rather than having an adversarial relationship with the EHR , nursing students should learn to consider the EHR as a care partner . By serving as a repository of data , providing alerts as needed , and facilitating communication , the EHR can help ensure quality patient care — and reduce nurses ’ risk of legal action . •
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