electronic medical record

  1. I'm just curious if anyone's clinic/facility is using the electroninc medical record or EMR? we document everything in our EMR system, we completely got rid off paper charting. We frequently receive faxes from nurses from assisted living and SNF re: updates about our patients... for example fall incident, wound problem, BP problem, medical issues, etc.... sometimes they call us and we nurses take this down and document it in the EMR. but for the most part, they send their reports via fax. Now our docs want us nurses to start transferring and transcribing this messages/reports in our EMR. They said we can use quotations but I still don't feel comfortable doing this. I feel that the fax report written already by another nurse is a legal written document and transcribing another nurse's report doesn't sound right to me? Is there a law regarding documetations like this? I just feel that transcribing itself leaves so much room for error , and not work efficient. I can understand why the docs want everything in the EMR, but is it legal what they are asking us to do?

    Thanks for your thoughts.
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    About nurse-rhe

    Joined: Oct '08; Posts: 4; Likes: 1
    Specialty: 3 year(s) of experience in ICU, ambulatory


  3. by   ldt1010
    we have EMR in our office. For faxes, or any other document on paper we have them scanned by the receptionist/front office into the patient's EMR. It doesn't seem right to me to rewrite info from other documents.