This post continues our series on Documentation for Correctional Nurses with a discussion of electronic health records.

The Electronic Health Record

Today, many systems are using an electronic health record (EHR).  The benefits of an EHR include improved legibility, improved efficiency, and improved availability of patient information to all staff.  The clinical decision support included in most EHRs today allows for better identification of drug interactions/allergy identification.  There are flags for abnormal laboratory values and patient encounter information that must be included before the progress note can be completed.  Some EHRs will also identify the need for additional assessments that must be completed on the patient based upon information entered about that patient.  An example is the patient who has been in the facility for 13 months and comes to Nursing Sick Call – their EHR will indicate that an annual physical should also be completed, and will open the appropriate form for  that encounter to occur.

Common pitfalls

Common pitfalls with using an EHR include poor spelling, grammar and punctuation; faulty “cut and paste” entries; use of the wrong template; ignoring Alerts; and omission of information.  Never use all capital letters.  Be aware of your punctuation, and be sure it is used properly to convey the correct information (Let’s eat John versus Let’s eat, John). Spelling is also very important, and if you are unsure, use a dictionary.  Some nurses keep a list of frequently misspelled words readily available.  Beware of spell check if it is automatically used in the EHR and make sure that any note written is reviewed before hitting the “Submit” button.

Abbreviations

Abbreviations are commonly used among healthcare workers as a time saving methodology. Unfortunately, abbreviation use is responsible for increased errors. Your institution should provide you with a list of acceptable abbreviations for use in documentation.  Ask if you do not have one.  Never use “texting” formats in the medical record (“IMHO this patient needs daily blood pressure checks.”).

The Institute for Safe Medication Practices, devoted entirely to prevention of medication errors and safe medication use, developed a list of error-prone abbreviations. This list is endorsed by the Joint Commission, The Federal Drug Administration, and the National Council for Medication Error Reporting and Prevention. Please take a moment and review it.

Cut and Paste

Be very cautious of using the “cut and paste” feature available in most word processing programs.  It can perpetuate an error or drop information if used incorrectly.  If you have a particular type of encounter where the wording would be the same for most patients, then the development of a template would be a better alternative than using the cut and paste feature.  If you do cut and paste information, be sure to double check the entry for accuracy and completeness prior to finalization.

Alert overload

Alerts in the EHR are important, but alert “overload” can quickly occur if the system is designed with a low tolerance for certain parameters.  It is important that each alert is addressed in some way, and that there is documentation in the EHR when an alert is overridden.  If you find that your system was set up with alerts that are not pertinent to your practice, after using it for a while (to be sure that they are not pertinent) you may want to discuss eliminating those from the system with your administration.  Most EHRs are editable in this area.

Templates

When using the EHR, be sure that you are in the correct template for the encounter you are documenting.  Many EHRs have mandatory fields that must be completed prior to closing the health record, but if yours does not, always be sure that all entries are completed.  Always document all pertinent information in the EHR – never have some information in the EHR, and other information in a paper chart or log on a shelf.

Protect Your Signature

Finally, protect your electronic signature!  Always completely log out of the EHR when you leave your work station.  To ensure that you are not documenting under another person’s signature, always make sure that you log in before each session.  Never share your username and password with anyone.

This post is based on The Correctional Nurse Educator class entitled Documentation for the Correctional Nurse. Please share any tips or tricks you have learned using an electronic health record.