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Computerized Charting Errors-Need Stories

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Karou

Specializes in Med-Surg. Has 1 years experience.

The most common errors that see always involve copy/paste.

Ex. Patients "goal" of the shift is, "NPO after midnight, I&D tomorrow at 09:00" charted the day of procedure at 10:00.

I have a LOT of problems with this. First, since you (oncoming RN) copy/pasted my assessment, I wonder if you even actually assessed the patient. I get so irritated when I see a nurse exact copied/pasted and it's no longer accurate.

Ex. On my assessment (19:30), patient found with labored breathing, rapid RR, pulse of 80%, wheezing/crackles, all the symptoms of fluid overload. After lasix administered, symptoms resolve, and I document my new assessment accordingly (at the time the symptoms resolve... So not in the column of my initial 19:30 assessment). Oncoming nurse copies and pastes my initial 19:30 assessment. So the patient developed fluid overload again? Because that's what "her" assessment looked like.

I also document a lot of interventions in my initial assessment since I try to cluster my care. Wound care, PICC dressing changes, ambulation, ect... That if copied/pasted by the next nurse look like they did them on their shift as well. Falsification of documentation if they actually weren't done on her shift.

I see (and have made) entries on the wrong patients chart. It's easy to have two tabs open and document on the wrong one.

Computer charting doesn't give a whole lot of room to elaborate or make extra notes. It seems like the bare minimum needed to "make it legal".

Nurses can start to glaze over with the 523 individual checkboxes that one has to go through. They may be user friendly, but after the 15th page, accuracy can become an issue.

What becomes a HUGE issue, and that I have seen nurse's get in hot water over is the lack of checking the box off for "patient education" THIS is one of the goals of the facility as it counts towards "meaningful use" which means that if a nurse does not do this, the facility will not get the max governmental reimbursement for converting to EMR's.

Seems as if no one cares if the infomation is accurate (unless they are caught in the act) but everyone is up in arms that the appropriate boxes are checked so they get paid.

Most data shows that EMR's have reduced errors, and that is partly true. However, EMR's have also introduced a host of new errors that were never a factor with hand written charts. Mistakes are being made in entirely new ways now. My focus is to highlight the areas where these new errors are being made and bring it to nurses attentions so that the errors can be prevented. Drop down menus, scanning, electronic signatures, computer glitches...the list goes on. I am not preaching against EMR's, just trying to increase awareness of new responsibilities.