Empowering Nurses at the Bedside and in Business

The Downside Of Electronic Medical Records Documentation

The electronic health records are here to stay.  You may love it because they save time or you may dislike it.  Regardless of your opinion, we have no choice about it.

The government now requires that healthcare providers adopt and demonstrate “meaningful use” of electronic health records to remain eligible for Medicare and Medicaid reimbursements.

“If it is not documented, it is not done.”  So, with that in mind, here are some tips to help you with these procedural changes:

  1. Always use approved abbreviations.
  2. Make sure you document in the records of the correct patient.
  3. When you begin typing in the EHR, it records the current time. If something happened prior to the time of typing, be sure to document the proper time and mark it as a “late entry.”
  4. If you enter information and find that it is not accurate, be sure to mark it as an “incorrect entry.” Anything that you might attempt to hide will not help the situation.
  5. Anything that you change in the electronic records can be identified in an audit trail. NEVER delete anything from an electronic medical record but use the proper technique to note that it was an error.  Even though you think you may have erased something, it is always
  6. Before clicking “enter,” double-check your entry. It is much easier to remove inaccurate information before it is saved as a part of the record.
  7. Never copy and paste someone else’s documentation or even your own. A nurse was recently placed on probation because she was accused of not taking vital signs, which she had documented.  Her defense was she inaccurately copied and pasted which did not fly.
  8. If you must copy and paste your own information, make sure that it is completely accurate. If your copy and paste contains something that was not actually done the second time.  This is a fraud.  Take the extra time you need to retype rather than copy/paste.

Keep in mind that if it wasn’t documented, it wasn’t done, as well as that any changes in the charting can be tracked in an audit.

Be very careful and be very aware.  You certainly don’t want to be accused of fraud or unprofessional conduct.

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