Nursing Notes May Be Hard to Find With EMRs
Nursing Notes May Be Hard to Find With EMRs
Attorneys will make use of discrepancies
"This is a new electronic record, and it does not work very well." If an emergency physician (EP) didn't review the nursing notes because these couldn't be located within the ED's electronic medical record (EMR), this statement could very well be the EP's only defense in the event a medical malpractice suit occurs, says Michael Blaivas, MD, FACEP, FAIUM, professor of emergency medicine at Northside Hospital Forsyth in Atlanta, GA.
"Physicians are left seeming poorly attentive when that is all they can say in a deposition," he says. "They will all say that they check nursing notes prior to seeing the patient. Then they have to go back and say, 'I never saw this,' or 'no one mentioned this.'"
Finding nursing documentation is quite cumbersome in some EMRs, in contrast to a simple written chart in which nursing notes are typically easy to see, says Blaivas.
"These may not even be available to the physician before the patient is seen and treatment decisions are made," he says. "The scripted style and large volume in EMR nursing notes makes it difficult to pick out specifics the nurse may have heard that would be helpful to know."
Robert B. Takla, MD, MBA, FACEP, chief of the Emergency Center at St. John Hospital and Medical Center in Detroit, MI, says that unnecessary and irrelevant documentation and possible discrepancies in the record are created due to parts of EMR charting being auto-completed or pre-populated.
While the documentation may be difficult for the EP to find, the plaintiff's attorney will carefully review it, says Blaivas. "It is then much harder for the EP to say, 'this was not available,' or 'it was charted wrong,'" he says.
Here are strategies for EPs to reduce legal risks regarding nursing documentation in EMRs:
Add late entries if necessary.
"Electronic records may be filled in later, just like written ones," says Blaivas. "I think in some cases, there is no option but to add a late entry and to be quite honest about it."
The EP should note the discrepancy, that it was discussed with the nurse, and explain why it occurred, he says, and avoid accusatory statements such as "I saw this in the record and he or she is wrong." Instead, Blaivas says EPs should simply state what was noted in reviewing the nursing notes and the fact that the EP followed-up with the patient or family about it.
If the EP doesn't read the nursing notes, says Blaivas, this should be acknowledged with a statement such as "no notes were available at this time due to the urgency of the patient," or "I obtained all of the information from the patient."
EPs should document or dictate that they spoke with the triage nurse and/or patient's nurse and asked them what they found, saw, or learned.
Verbal checks are particularly important with EMRs because so many things can go wrong with documentation, according to Blaivas. "I have read multiple depositions lately where nurses are saying 'I don't remember documenting this I am sure it was really the following ....'" he says.
Nurses should be careful not to assume that something they chart will be seen by the EP in a timely manner, stresses Takla. "All abnormalities or concerns need to also be brought to the physician's attention," he says. "In the same manner that laboratory abnormalities are highlighted, so should any nursing documentation that is abnormal."
Take a careful look at the electronic records generated on a patient, especially a complex one, after their care is finished.
"You may be surprised just how much is not accurate, difficult to follow, and how much room there is for error," says Blaivas.
Utilize a system that makes it easy to locate nursing documentation.
Ann Robinson, MSN, RN, CEN, LNC, principle of Robinson Consulting, a Cambridge, MD-based legal nurse consulting company, says the particular EMR she uses requires multiple "point and click" steps to move from page to page.
Robinson advises purchasing systems that automatically put nursing and physician documentation in an easy-to-find location. "There are such systems out there," she says. "The issue is often a financial one, of course, since the systems that are easier to navigate are often more costly."
For more information, contact:
Michael Blaivas, MD, FACEP, FAIUM, Professor of Emergency Medicine, Northside Hospital Forsyth, Atlanta, GA. Phone: (706) 414-5496. E-mail: [email protected]
Robert B. Takla, MD, MDA, FACEP, Chief, Emergency Center, St. John Hospital and Medical Center, Detroit, MI. Phone: (313) 343-7071. E-mail: [email protected]
Ann Robinson, MSN, RN, CEN, LNC, Robinson Consulting, Cambridge, MD. Phone: (410) 463-3770. E-mail: [email protected]"This is a new electronic record, and it does not work very well." If an emergency physician (EP) didn't review the nursing notes because these couldn't be located within the ED's electronic medical record (EMR), this statement could very well be the EP's only defense in the event a medical malpractice suit occurs, says Michael Blaivas, MD, FACEP, FAIUM, professor of emergency medicine at Northside Hospital Forsyth in Atlanta, GA.
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