Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:The Culture of Health Care
Unit:Nursing Care Processes
Lecture:Nursing routines and procedures including performing invasive procedures, administering medication, documenting procedures, and using technology
Slide content:Rules for Filling Out the Patients Chart Make the record clear and comprehensible by others Record data accurately: Use approved abbreviations Be objective, clear, specific, descriptive, and concise Indicate errors or late entries appropriately Electronic health records facilitate the complete and accurate patient record 17
Slide notes:Documentation in the patients chart, which is typically done electronically, needs to be clear and thorough. Nurses need to record data accurately and indicate errors or late entries appropriately. Date and time of each action they take for a patient needs to be documented. Information systems typically automatically track the date and time of data entry, which can be used for auditing purposes. For any handwritten records, the nurse should write legibly in permanent black ink and sign every entry. If an entry is written late, the nurse should mark it as a late entry and record when the entry was written. Although electronic health record systems include numerous drop-down menu items, some fields are unstructured and allow providers to enter text. So that others can read the chart accurately, the nurse should use only approved and recognized medical abbreviations and symbols. Unless he or she is quoting someone, the nurse should not use slang. All entries should be objective, and the nurse should use details to support his or her interpretations. To prevent any unauthorized additions to the record, the nurse should draw a line through any blank lines or spaces in handwritten records. This is not an issue with clinical systems. To correct the chart, the nurse should draw one line through an error, write the correct information, and date and initial the correction. Clinical systems should have a process by which to provide an addendum and corrections for the record. Electronic medical records have greatly impacted the ability of clinicians to effectively document patient care and have improved overall accessibility and management of the record. But researchers have found that nurses have three main frustrations with electronic documentation. Some systems are designed poorly, some systems are not integrated well with each other, and some systems create redundant documentation. These frustrations usually link back to the overall success of the electronic health record implementation and how well the system is aligned with workflow processes. Ideally, system implementations should be considered a three-legged stool that comprises technology, people, and process. These three pieces must be addressed for overall success of any system implementation. 17