Effective use of EHRs These actions will help you gain the most benefit from the EHR :
Document promptly and thoroughly . This not only helps protect you from liability but , more importantly , ensures that information is quickly available to other providers .
Document accurately . Don ’ t omit key information and don ’ t try to cover up if you failed to document or take correct action . Follow your organization ’ s policies regarding documenting late entries or correcting prior entries .
Identify opportunities for improvements in EHR function . Instead of engaging in potentially dangerous workarounds , notify leadership when improvements are needed . In some cases , the format of the EHR can be tweaked to make it easier for the user .
Don ’ t assume the EHR is always right . The EHR isn ’ t infallible . If , for example , results of a test don ’ t seem to match the patient ’ s symptoms , follow up with the provider – the test may need to be redone .
Provide education . Consider helping your colleagues to learn more about proper documentation in the EHR by providing an education program or suggesting such a program to your professional development department .
Be patient centered . The ability to document at the patient ’ s bedside can save time and improve accuracy , but only if you keep your focus on the patient instead of on the computer . Maintain eye contact and consider telling patients what you are entering into the computer , which can help ensure the information is accurate .
References
Balestra ML . Electronic health records : Patient care and ethical and legal implications for nurse practitioners . J Nurs Pract . 2017 ; 13 ( 2 ): 105-111 .
CNA , NSO . Nurse Professional Liability Exposure Claim Report : 4th Edition . 2020 . www . nso . com / Learning / Artifacts / Claim-Reports / Nurse-Practitioner-Claim-Report-4th-Edition-A-Guide-to-Identifying-and-Addressing-Professional-Liability-Exposures
CNA , NSO . Nurse Professional Liability Exposures : 2015 Claim Report Update . 2015 . Retrieved from https :// www . cna . com / web / wcm / connect / e05b5d91-cf38-444d-8727-ab65f25f8f6a / RC _ Health _ Nurses _ Claim _ Report _ Update _ 101615 . pdf ? MOD = AJPERES & CACHEID = e 05b5d91-cf38-444d-8727-ab65f25f8f6a
ECRI Institute . Copy / Paste : Prevalence , Problems , and Best Practices . Special Report . 2015 . Retrieved from https :// www . ecri . org / Resources / HIT / CP _ Toolkit / CopyPaste _ Literature _ final . pdf .
Kelley T . Electronic Health Records for Quality Nursing and Health Care . Lancaster , PA : DEStech Publications ; 2016 .
Pagulayan J , Eltair S , Faber K . Nurse documentation and the electronic health record . Am Nurs Today . 2018 ; 13 ( 9 ): 48-52 , 54 .
Partnership for Health IT Patient Safety . Health IT Safe Practices : Toolkit for the Safe Use of Copy and Paste . 2016 . Retrieved from https :// d84vr99712pyz . cloudfront . net / p / pdf / hit-partnership / copy-paste-toolkit . pdf .
Tsou AY , Lehmann CU , Michel J , et al . Safe practices for copy and paste in the EHR . Appl Clin Inform . 2017 ; 8 ( 1 ): 12-34 .
This risk management information was provided by Nurses Service Organization ( NSO ), the nation ’ s largest provider of nurses ’ professional liability insurance coverage for over 550,000 nurses since 1976 . The individual professional liability insurance policy administered through NSO is underwritten by American Casualty Company of Reading , Pennsylvania , a CNA company . Reproduction without permission of the publisher is prohibited . For questions , send an e-mail to service @ nso . com or call 1-800-247-1500 .
www . nso . com .
Georgia Reiner , MS , is a Risk Specialist for Nurses Service Organization ( NSO ) in the Healthcare Division of Aon ’ s Affinity Insurance Services , Inc . She earned a BS in Healthcare Policy and Administration from Penn State University , a certificate in Paralegal Studies from Villanova University and is a licensed property and casualty insurance producer . At NSO , she is responsible
Reiner for educating healthcare professionals on professional
liability issues and risk management strategies by creating informative risk management content , including self-assessment tools , newsletters , webinars , and claim reports .
30 NSNA IMPRINT • NOVEMBER / DECEMBER 2021 • www . nsna . org